Provider Demographics
NPI:1679248082
Name:MCCOY, MACK
Entity Type:Individual
Prefix:
First Name:MACK
Middle Name:
Last Name:MCCOY
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 1:2 WHARTON CT
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92617-4108
Mailing Address - Country:US
Mailing Address - Phone:949-371-6225
Mailing Address - Fax:
Practice Address - Street 1:2 WHARTON CT
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92617-4108
Practice Address - Country:US
Practice Address - Phone:949-371-6225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74342225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA74342OtherCAMTC CERTIFICATION
1445509OtherAMTA MEMBERSHIP