Provider Demographics
NPI:1083903090
Name:SUPRENAND, SCOTT THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:THOMAS
Last Name:SUPRENAND
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 S PIONEER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-3800
Mailing Address - Country:US
Mailing Address - Phone:920-872-2969
Mailing Address - Fax:920-933-2511
Practice Address - Street 1:103 S PIONEER RD STE 200
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-3800
Practice Address - Country:US
Practice Address - Phone:920-872-2969
Practice Address - Fax:920-933-2511
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4745-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor