Provider Demographics
NPI:1538416300
Name:LACIAK, MARK A (DPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:LACIAK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W WACKERLY ST STE 3600
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4714
Mailing Address - Country:US
Mailing Address - Phone:989-631-3570
Mailing Address - Fax:
Practice Address - Street 1:555 W WACKERLY ST STE 3600
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4714
Practice Address - Country:US
Practice Address - Phone:989-631-3570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014078225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist