Healthcare Provider Details

I. General information

NPI: 1588949028
Provider Name (Legal Business Name): THERESA MARIE TENGLER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 HILLSIDE DR STE A
DELAFIELD WI
53018-2165
US

IV. Provider business mailing address

2415 MADISON ST ENTER YOUR SECOND ADDRESS
WAUKESHA WI
53188-4627
US

V. Phone/Fax

Practice location:
  • Phone: 262-646-2123
  • Fax:
Mailing address:
  • Phone: 262-894-0330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number01044099
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: