Provider Demographics
NPI:1720865397
Name:MACK, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ABOC, NCLC
Mailing Address - Street 1:10 SANBORN ST
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-2229
Mailing Address - Country:US
Mailing Address - Phone:207-651-4078
Mailing Address - Fax:
Practice Address - Street 1:500 GALLERY BLVD
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-6606
Practice Address - Country:US
Practice Address - Phone:207-287-0160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1936156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician