1922626670 NPI number — ERIC WILLIAM BROSTROM MS, LAT, ATC

Table of content: ERIC WILLIAM BROSTROM MS, LAT, ATC (NPI 1922626670)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922626670 NPI number — ERIC WILLIAM BROSTROM MS, LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROSTROM
Provider First Name:
ERIC
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, LAT, ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922626670
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N73W6913 WALNUT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDARBURG
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53012-1165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-459-8343
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3305 LILLY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53005-7608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-781-3500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/09/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  1909-39 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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