Provider Demographics
NPI:1225542301
Name:PLONKA, CRAIG ALVIN (ATC)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:ALVIN
Last Name:PLONKA
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8928 LOUISE ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-4016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19556 HARPER AVE
Practice Address - Street 2:
Practice Address - City:HARPER WOODS
Practice Address - State:MI
Practice Address - Zip Code:48225-2037
Practice Address - Country:US
Practice Address - Phone:313-885-6491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010011712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer