Healthcare Provider Details

I. General information

NPI: 1750328605
Provider Name (Legal Business Name): TRACY BRETL, D.O., S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 W COVENTRY CT
GLENDALE WI
53217-3972
US

IV. Provider business mailing address

250 W COVENTRY CT
GLENDALE WI
53217-3966
US

V. Phone/Fax

Practice location:
  • Phone: 414-351-8444
  • Fax: 414-351-0678
Mailing address:
  • Phone: 414-351-8444
  • Fax: 414-351-0678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number31707
License Number StateWI

VIII. Authorized Official

Name: DR. TRACY LYNN BRETL
Title or Position: PRESIDENT
Credential: D.O.
Phone: 414-351-1844