Active NPI
Trenton Demetrius Mack, LMT
- Massage Therapist
- Decatur, GA
National Provider Identifier
1790374338
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Massage Therapist
- License
- MT012952
- Practice address
- 1953 Crestmoore Dr
Decatur, GA 30032-4909 - Phone
- (770) 883-5839
- NPI assigned
- Jan 17, 2021
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Massage Therapist | 225700000X | MT012952 | GA | Primary |
Addresses
Primary practice location
1953 Crestmoore Dr
Decatur, GA 30032-4909
Mailing address
1953 Crestmoore Dr
Decatur, GA 30032-4909
Phone (770) 883-5839
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| MT012952 | GA | MD | Massage Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1610841600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1610841600000",
"number": "1790374338",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1953 CRESTMOORE DR",
"city": "DECATUR",
"state": "GA",
"postal_code": "300324909",
"telephone_number": "770-883-5839"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1953 CRESTMOORE DR",
"city": "DECATUR",
"state": "GA",
"postal_code": "300324909",
"telephone_number": "770-883-5839"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MACK",
"first_name": "TRENTON",
"middle_name": "DEMETRIUS",
"credential": "LMT",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2021-01-17",
"last_updated": "2021-01-17",
"certification_date": "2021-01-17",
"status": "A"
},
"taxonomies": [
{
"code": "225700000X",
"taxonomy_group": "",
"desc": "Massage Therapist",
"state": "GA",
"license": "MT012952",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Decatur, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 17, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.