Provider Demographics
NPI:1932317096
Name:WRUCK, SCOTT HAROLD (DC)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:HAROLD
Last Name:WRUCK
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 1:940 HANSEN RD
Mailing Address - Street 2:STE F
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5376
Mailing Address - Country:US
Mailing Address - Phone:920-494-6211
Mailing Address - Fax:920-494-6219
Practice Address - Street 1:940 HANSEN RD
Practice Address - Street 2:STE F
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5376
Practice Address - Country:US
Practice Address - Phone:920-494-6211
Practice Address - Fax:920-494-6219
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3434111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35469Medicare ID - Type Unspecified