Healthcare Provider Details

I. General information

NPI: 1316935083
Provider Name (Legal Business Name): BRIAN J MILNARICH LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 05/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N496 MILKY WAY
APPLETON WI
54915-3993
US

IV. Provider business mailing address

N9642 COUNTY RD N
APPLETON WI
54915-9312
US

V. Phone/Fax

Practice location:
  • Phone: 920-420-4371
  • Fax:
Mailing address:
  • Phone: 920-420-4371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number55639
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: