Provider Demographics
NPI:1891562344
Name:WHACK, MONDREEK
Entity type:Individual
Prefix:
First Name:MONDREEK
Middle Name:
Last Name:WHACK
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 1:4125 DOVE RD
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-7454
Mailing Address - Country:US
Mailing Address - Phone:248-658-8665
Mailing Address - Fax:
Practice Address - Street 1:4125 DOVE RD LOT 49
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-7458
Practice Address - Country:US
Practice Address - Phone:248-658-8665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant