Provider Demographics
NPI:1881841401
Name:MACK, CARL DAWES (PTA)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:DAWES
Last Name:MACK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 AFEHA LANE
Mailing Address - Street 2:PO BOX 430
Mailing Address - City:GILBERTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42044
Mailing Address - Country:US
Mailing Address - Phone:270-362-5004
Mailing Address - Fax:
Practice Address - Street 1:17 AFHEA LN
Practice Address - Street 2:
Practice Address - City:GILBERTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42044-8806
Practice Address - Country:US
Practice Address - Phone:270-362-5004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA00108225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant