Provider Demographics
NPI:1568057172
Name:MAIN, ZACKERY ALAN
Entity Type:Individual
Prefix:
First Name:ZACKERY
Middle Name:ALAN
Last Name:MAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2586 HICKORYVALE DR
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-6936
Mailing Address - Country:US
Mailing Address - Phone:270-570-4617
Mailing Address - Fax:
Practice Address - Street 1:2586 HICKORYVALE DR
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-6936
Practice Address - Country:US
Practice Address - Phone:270-570-4617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty