Provider Demographics
NPI:1104992619
Name:GALEN MACK
Entity type:Organization
Organization Name:GALEN MACK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GALEN
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-579-0381
Mailing Address - Street 1:5975 ROSWELL RD NE
Mailing Address - Street 2:SUITE B205
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4048
Mailing Address - Country:US
Mailing Address - Phone:404-255-7200
Mailing Address - Fax:404-255-7211
Practice Address - Street 1:5975 ROSWELL RD NE
Practice Address - Street 2:SUITE B205
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-4048
Practice Address - Country:US
Practice Address - Phone:404-255-7200
Practice Address - Fax:404-255-7211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA641666367AMedicaid
GA641666367AMedicaid