Provider Demographics
NPI:1871810226
Name:WACK, SCOT ALEXANDER (CMT, NBCA)
Entity type:Individual
Prefix:MR
First Name:SCOT
Middle Name:ALEXANDER
Last Name:WACK
Suffix:
Gender:M
Credentials:CMT, NBCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10655 E MELKILD RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49670-9630
Mailing Address - Country:US
Mailing Address - Phone:231-386-7708
Mailing Address - Fax:
Practice Address - Street 1:109 NAGONABA ST
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:MI
Practice Address - Zip Code:49670
Practice Address - Country:US
Practice Address - Phone:231-386-7708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other