Provider Demographics
NPI:1477690097
Name:KACZMAR, SCOTT (DC)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:KACZMAR
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 1:47950 VAN DYKE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-3255
Mailing Address - Country:US
Mailing Address - Phone:586-739-6654
Mailing Address - Fax:
Practice Address - Street 1:47950 VAN DYKE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48317-3255
Practice Address - Country:US
Practice Address - Phone:586-739-6654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISK007679111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950E025430OtherBLUE CROSS BLUE SHEILD
MIU78085Medicare UPIN
MI950E025430OtherBLUE CROSS BLUE SHEILD