Healthcare Provider Details

I. General information

NPI: 1033755657
Provider Name (Legal Business Name): NATHAN SAMUEL HOTH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3113 W BELTLINE HWY STE 300
MADISON WI
53713-2934
US

IV. Provider business mailing address

3113 W BELTLINE HWY STE 300
MADISON WI
53713-2934
US

V. Phone/Fax

Practice location:
  • Phone: 608-819-6810
  • Fax: 224-258-1400
Mailing address:
  • Phone: 608-819-6810
  • Fax: 224-258-1400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-92558
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: