Healthcare Provider Details

I. General information

NPI: 1215719075
Provider Name (Legal Business Name): MARC VIERGUTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2023
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E SOUTH RIVER ST
APPLETON WI
54915-2222
US

IV. Provider business mailing address

W6607 E MIDWAY RD APT 88
APPLETON WI
54915-4867
US

V. Phone/Fax

Practice location:
  • Phone: 920-832-6760
  • Fax:
Mailing address:
  • Phone: 303-248-6821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2545
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: