Healthcare Provider Details

I. General information

NPI: 1972868529
Provider Name (Legal Business Name): CHRISTOPHER CHARLES YACK B.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 PARK AVE
MALVERNE NY
11565-1916
US

IV. Provider business mailing address

17 PARK AVE
MALVERNE NY
11565-1916
US

V. Phone/Fax

Practice location:
  • Phone: 516-837-3343
  • Fax: 516-837-3343
Mailing address:
  • Phone: 516-837-3343
  • Fax: 516-837-3343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2279246
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: