Healthcare Provider Details

I. General information

NPI: 1326495425
Provider Name (Legal Business Name): BRYAN GREWER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6692 ODANA RD
MADISON WI
53719-1012
US

IV. Provider business mailing address

1802 GALLOWAY ST., EA VALLEY HEARING, D/B/A MIRACLE-EAR
EAU CLAIRE WI
54703
US

V. Phone/Fax

Practice location:
  • Phone: 608-829-3777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1490-60
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: