Healthcare Provider Details

I. General information

NPI: 1013066729
Provider Name (Legal Business Name): BARBARA SUE GROBE DTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E VETERANS ST
TOMAH WI
54660-3105
US

IV. Provider business mailing address

500 E VETERANS ST
TOMAH WI
54660-3105
US

V. Phone/Fax

Practice location:
  • Phone: 608-372-1774
  • Fax:
Mailing address:
  • Phone: 608-372-1774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number883795
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: