Provider Demographics
NPI:1972367696
Name:MACK, STACY R
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:R
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 1:1370 W RIDGE RD # 1077
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14615-2418
Mailing Address - Country:US
Mailing Address - Phone:585-443-6688
Mailing Address - Fax:
Practice Address - Street 1:16 ATLEE DRIVE
Practice Address - Street 2:LOWER
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626
Practice Address - Country:US
Practice Address - Phone:585-704-0974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY365956754172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver