Healthcare Provider Details

I. General information

NPI: 1295848869
Provider Name (Legal Business Name): NICHOLAS TALARCZYK PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 MIDWAY RD
MENASHA WI
54952-1014
US

IV. Provider business mailing address

4000 N PROVIDENCE AVE
APPLETON WI
54913-8018
US

V. Phone/Fax

Practice location:
  • Phone: 920-727-9878
  • Fax: 920-727-9903
Mailing address:
  • Phone: 920-257-2000
  • Fax: 920-257-2004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3245-024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: