Provider Demographics
NPI:1922350271
Name:MACK, DOLORES M (CHAII)
Entity Type:Individual
Prefix:
First Name:DOLORES
Middle Name:M
Last Name:MACK
Suffix:
Gender:F
Credentials:CHAII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3380 C STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANCHROAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-3949
Mailing Address - Country:US
Mailing Address - Phone:907-277-1440
Mailing Address - Fax:907-277-1436
Practice Address - Street 1:40 MAIN STREET
Practice Address - Street 2:
Practice Address - City:NELSON LAGOON
Practice Address - State:AK
Practice Address - Zip Code:99571
Practice Address - Country:US
Practice Address - Phone:907-989-2202
Practice Address - Fax:907-277-1436
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker