Provider Demographics
NPI:1902230394
Name:DR. MACK, LLC
Entity Type:Organization
Organization Name:DR. MACK, LLC
Other - Org Name:GYNECOLOGY EMERGENT CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MACKOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:855-376-2496
Mailing Address - Street 1:3711 LONG BEACH BLVD
Mailing Address - Street 2:SUITE 101 B
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3315
Mailing Address - Country:US
Mailing Address - Phone:855-376-2496
Mailing Address - Fax:
Practice Address - Street 1:3711 LONG BEACH BLVD
Practice Address - Street 2:SUITE 101 B
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3315
Practice Address - Country:US
Practice Address - Phone:855-376-2496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care