Healthcare Provider Details

I. General information

NPI: 1558599332
Provider Name (Legal Business Name): ADAM J BRILL L.A.T., A.T.C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 07/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 N 6TH ST
SHEBOYGAN WI
53083-4963
US

IV. Provider business mailing address

2640 N 6TH ST
SHEBOYGAN WI
53083-4963
US

V. Phone/Fax

Practice location:
  • Phone: 920-451-5559
  • Fax: 920-451-5664
Mailing address:
  • Phone: 920-451-5559
  • Fax: 920-451-5664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number925-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: