Provider Demographics
NPI:1124601448
Name:MACKIE WELLNESS LLC
Entity type:Organization
Organization Name:MACKIE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MACKIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:458-230-5248
Mailing Address - Street 1:701 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-9559
Mailing Address - Country:US
Mailing Address - Phone:458-230-5248
Mailing Address - Fax:
Practice Address - Street 1:701 N 5TH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-9559
Practice Address - Country:US
Practice Address - Phone:458-230-5248
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty