Provider Demographics
NPI:1497038699
Name:MACK, IRENE
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-3212
Mailing Address - Country:US
Mailing Address - Phone:870-735-2007
Mailing Address - Fax:870-735-2025
Practice Address - Street 1:225 N 5TH ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-3212
Practice Address - Country:US
Practice Address - Phone:870-735-2007
Practice Address - Fax:870-735-2025
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X, 3747A0650X
AR253Z00000X376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH445614Medicaid
AR184245732Medicaid