Healthcare Provider Details

I. General information

NPI: 1053374058
Provider Name (Legal Business Name): BRIAN L ZELLER PHD, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 W MARK ST
WINONA MN
55987-3384
US

IV. Provider business mailing address

167 E 5TH ST
WINONA MN
55987-3522
US

V. Phone/Fax

Practice location:
  • Phone: 507-457-5575
  • Fax: 507-457-5606
Mailing address:
  • Phone: 507-457-5575
  • Fax: 507-457-5606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1543
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: