Provider Demographics
NPI:1568136737
Name:FLACK, GREGORY L
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:L
Last Name:FLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W9491 COUNTY ROAD B
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:WI
Mailing Address - Zip Code:54418-9786
Mailing Address - Country:US
Mailing Address - Phone:715-610-0836
Mailing Address - Fax:
Practice Address - Street 1:W9491 COUNTY ROAD B
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:WI
Practice Address - Zip Code:54418-9786
Practice Address - Country:US
Practice Address - Phone:715-610-0836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)