Healthcare Provider Details

I. General information

NPI: 1841795911
Provider Name (Legal Business Name): ZACHARY FUCIK FAHRENKRUG ATC, LAT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 KELLER AVE N
AMERY WI
54001-1036
US

IV. Provider business mailing address

207 JADEN DR
MILLTOWN WI
54858-9075
US

V. Phone/Fax

Practice location:
  • Phone: 715-268-1008
  • Fax:
Mailing address:
  • Phone: 920-460-2208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1603
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: