Healthcare Provider Details

I. General information

NPI: 1013045103
Provider Name (Legal Business Name): BRIAN JOSEPH MEITNER L.A.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E TYRANENA PARK RD
LAKE MILLS WI
53551-9678
US

IV. Provider business mailing address

W9561 GRACE LN
CAMBRIDGE WI
53523-9753
US

V. Phone/Fax

Practice location:
  • Phone: 920-648-8170
  • Fax: 920-648-8225
Mailing address:
  • Phone: 608-423-4011
  • Fax: 608-423-3889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number65-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: