Healthcare Provider Details

I. General information

NPI: 1679502504
Provider Name (Legal Business Name): MARK WAYNE FRAZIER RKT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2006
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

15052 HELM RD
TOMAH WI
54660-6837
US

V. Phone/Fax

Practice location:
  • Phone: 608-372-3971
  • Fax:
Mailing address:
  • Phone: 608-372-0797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number1168
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: