Provider Demographics
NPI:1447627047
Name:MACKEN, ALEXANDER (PT)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:MACKEN
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 1:4761 LAKE MICHIGAN DR NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-6300
Mailing Address - Country:US
Mailing Address - Phone:269-372-1027
Mailing Address - Fax:269-372-2940
Practice Address - Street 1:2425 W WASHINGTON
Practice Address - Street 2:SUITE B
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-8259
Practice Address - Country:US
Practice Address - Phone:616-225-2325
Practice Address - Fax:269-372-2940
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017347225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist