Provider Demographics
NPI:1255169421
Name:MACK, ANGELO C (LMT)
Entity type:Individual
Prefix:
First Name:ANGELO
Middle Name:C
Last Name:MACK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 MCDONNELL AVE APT A18
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-4218
Mailing Address - Country:US
Mailing Address - Phone:228-313-1763
Mailing Address - Fax:
Practice Address - Street 1:2033 E PASS RD STE C
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3714
Practice Address - Country:US
Practice Address - Phone:228-313-1763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3787225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist