Healthcare Provider Details

I. General information

NPI: 1235124157
Provider Name (Legal Business Name): ROLAND JOSEPH SCHMIDT LAT/ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N WEBSTER AVE
GREEN BAY WI
54301-4813
US

IV. Provider business mailing address

408 MAIN ST
WRIGHTSTOWN WI
54180-1056
US

V. Phone/Fax

Practice location:
  • Phone: 920-433-3638
  • Fax:
Mailing address:
  • Phone: 920-532-0657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number228-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: