Provider Demographics
NPI:1134192321
Name:MACK, RAYMOND (PT)
Entity type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:
Last Name:MACK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 E ENTERPRISE AVE STE 113
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7862
Mailing Address - Country:US
Mailing Address - Phone:920-560-1147
Mailing Address - Fax:920-560-1197
Practice Address - Street 1:924 BUFFALO ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-4618
Practice Address - Country:US
Practice Address - Phone:920-560-1147
Practice Address - Fax:920-560-1197
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1765024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400171921Medicare PIN