Provider Demographics
NPI:1578120408
Name:MACK, PORTIA
Entity Type:Individual
Prefix:
First Name:PORTIA
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 PINE SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-6333
Mailing Address - Country:US
Mailing Address - Phone:803-369-9848
Mailing Address - Fax:
Practice Address - Street 1:807 PINE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-6333
Practice Address - Country:US
Practice Address - Phone:803-369-9848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-27
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC106S00000X
372600000X, 376J00000X, 376K00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide