Healthcare Provider Details

I. General information

NPI: 1730680539
Provider Name (Legal Business Name): BADGER IOM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 08/12/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4321 W COLLEGE AVE SUITE 200
APPLETON WI
54914
US

IV. Provider business mailing address

1141 N LOOP 1604 E #105-612
SAN ANTONIO TX
78232-0046
US

V. Phone/Fax

Practice location:
  • Phone: 210-598-4277
  • Fax:
Mailing address:
  • Phone: 210-598-4277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name: ROXANNA LAROQUE
Title or Position: DIRECTOR OF CLIENT EXPERIENCE
Credential:
Phone: 210-598-4277