Healthcare Provider Details

I. General information

NPI: 1477922250
Provider Name (Legal Business Name): BRADY SCHRAUTH LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2015
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 S RIDGE RD
GREEN BAY WI
54304-4125
US

IV. Provider business mailing address

3404 MEMORIAL DR APT J3
TWO RIVERS WI
54241-3259
US

V. Phone/Fax

Practice location:
  • Phone: 262-305-1628
  • Fax:
Mailing address:
  • Phone: 262-305-1628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: