Provider Demographics
NPI:1508162355
Name:MACK, LEROY JR (RN)
Entity Type:Individual
Prefix:MR
First Name:LEROY
Middle Name:
Last Name:MACK
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3755 WARRENSVILLE CENTER RD
Mailing Address - Street 2:APT 2
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-6381
Mailing Address - Country:US
Mailing Address - Phone:216-333-9839
Mailing Address - Fax:
Practice Address - Street 1:3755 WARRENSVILLE CENTER RD
Practice Address - Street 2:APT 2
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-6381
Practice Address - Country:US
Practice Address - Phone:216-333-9839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH365521163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse