Provider Demographics
NPI:1821323072
Name:MACKY ENTERPRISES PC
Entity Type:Organization
Organization Name:MACKY ENTERPRISES PC
Other - Org Name:PEACHTREE CHILDRENS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLON
Authorized Official - Middle Name:
Authorized Official - Last Name:MCALLISTER-BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-446-1818
Mailing Address - Street 1:5380 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:140
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-4713
Mailing Address - Country:US
Mailing Address - Phone:770-446-1818
Mailing Address - Fax:770-446-1808
Practice Address - Street 1:5380 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:140
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-4713
Practice Address - Country:US
Practice Address - Phone:770-446-1818
Practice Address - Fax:770-446-1808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-06
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061299208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty