Provider Demographics
NPI:1588783492
Name:MACK, ANTHONY R (PT)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:R
Last Name:MACK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:TONY
Other - Middle Name:R
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:1015 UNION ST
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:IA
Mailing Address - Zip Code:50036-4821
Mailing Address - Country:US
Mailing Address - Phone:515-432-7729
Mailing Address - Fax:515-433-0701
Practice Address - Street 1:1015 UNION ST
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:IA
Practice Address - Zip Code:50036-4821
Practice Address - Country:US
Practice Address - Phone:515-432-7729
Practice Address - Fax:515-433-0701
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00886225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist