Healthcare Provider Details

I. General information

NPI: 1760659122
Provider Name (Legal Business Name): TRACY L EICK PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SUNSHINE BLVD
SOLDIERS GROVE WI
54655-7106
US

IV. Provider business mailing address

15098 SIME RD
FERRYVILLE WI
54628-7077
US

V. Phone/Fax

Practice location:
  • Phone: 608-624-5422
  • Fax:
Mailing address:
  • Phone: 608-734-3285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number953-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: