Healthcare Provider Details

I. General information

NPI: 1457740979
Provider Name (Legal Business Name): JEFFREY ALLEN CIESLAK LAT,AT,C, EMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2015
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W RIVERWOODS PKWY
GLENDALE WI
53212
US

IV. Provider business mailing address

34565 MEADOW VIEW CT
OCONOMOWOC WI
53066-8778
US

V. Phone/Fax

Practice location:
  • Phone: 414-465-3000
  • Fax:
Mailing address:
  • Phone: 262-853-1629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0000195-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: