Provider Demographics
NPI:1588209365
Name:MACK, CHARLIE II (EP)
Entity type:Individual
Prefix:MR
First Name:CHARLIE
Middle Name:
Last Name:MACK
Suffix:II
Gender:M
Credentials:EP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:1745 S HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-1852
Mailing Address - Country:US
Mailing Address - Phone:727-767-0955
Mailing Address - Fax:727-587-0527
Practice Address - Street 1:8900 PARK BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33777-4119
Practice Address - Country:US
Practice Address - Phone:727-545-4545
Practice Address - Fax:727-548-1360
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL224Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist