Provider Demographics
NPI:1770740409
Name:MACK, KAREN ELIZABETH
Entity type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:ELIZABETH
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 1:5275 SW 133RD AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-5231
Mailing Address - Country:US
Mailing Address - Phone:305-227-4209
Mailing Address - Fax:305-227-4209
Practice Address - Street 1:5275 SW 133RD AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-5231
Practice Address - Country:US
Practice Address - Phone:305-227-4209
Practice Address - Fax:305-227-4209
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLKHU-0108-688-84171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL300096600Medicaid