Provider Demographics
NPI:1134188832
Name:MACK, BRANDON LEE (DPT)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:LEE
Last Name:MACK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29559 KATYDID
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MO
Mailing Address - Zip Code:63549-1136
Mailing Address - Country:US
Mailing Address - Phone:660-332-4960
Mailing Address - Fax:
Practice Address - Street 1:JUNCTION S. HWY 63 & 6E
Practice Address - Street 2:OUTPATIENT PHYSICAL THERAPY
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501
Practice Address - Country:US
Practice Address - Phone:660-785-1834
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004021474225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO858341605Medicaid