Provider Demographics
NPI:1093772212
Name:MACK, LORI L (RD)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:L
Last Name:MACK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 146TH LN NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-3401
Mailing Address - Country:US
Mailing Address - Phone:804-943-8507
Mailing Address - Fax:
Practice Address - Street 1:15251 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:CENTER CITY
Practice Address - State:MN
Practice Address - Zip Code:55012
Practice Address - Country:US
Practice Address - Phone:651-213-4407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2435133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered