Healthcare Provider Details

I. General information

NPI: 1356434526
Provider Name (Legal Business Name): BRENT DAVID KOWALKE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 12/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1468 N HIGH POINT RD
MIDDLETON WI
53562-3683
US

IV. Provider business mailing address

1468 N HIGH POINT RD
MIDDLETON WI
53562-3683
US

V. Phone/Fax

Practice location:
  • Phone: 608-833-7422
  • Fax: 608-833-7421
Mailing address:
  • Phone: 608-833-7422
  • Fax: 608-833-7421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4240012
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: