Provider Demographics
NPI:1790082436
Name:MACK, SUSAN L (HOMEOPATH/ND)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:MACK
Suffix:
Gender:F
Credentials:HOMEOPATH/ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1030
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30566-0018
Mailing Address - Country:US
Mailing Address - Phone:678-777-6484
Mailing Address - Fax:770-967-6835
Practice Address - Street 1:6484 FORD RD
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-2636
Practice Address - Country:US
Practice Address - Phone:678-777-6484
Practice Address - Fax:770-967-6835
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA13694175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath