Healthcare Provider Details

I. General information

NPI: 1326004052
Provider Name (Legal Business Name): SCOTT ALLAN DALCHOW LAT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E GRANT ST
APPLETON WI
54911-3483
US

IV. Provider business mailing address

1036 SCHEURING RD
DE PERE WI
54115-1802
US

V. Phone/Fax

Practice location:
  • Phone: 920-831-5050
  • Fax:
Mailing address:
  • Phone: 920-339-0977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number196-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: