Healthcare Provider Details

I. General information

NPI: 1578181657
Provider Name (Legal Business Name): BRODEN SCHOCK AT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2020
Last Update Date: 07/06/2020
Certification Date: 07/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 KELLER AVE N
AMERY WI
54001-1036
US

IV. Provider business mailing address

1503 85TH AVE
AMERY WI
54001-4947
US

V. Phone/Fax

Practice location:
  • Phone: 715-268-1008
  • Fax:
Mailing address:
  • Phone: 715-557-1086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2168-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: