Healthcare Provider Details

I. General information

NPI: 1760448617
Provider Name (Legal Business Name): BEETHOVEN CARABACAN LAT, CSCS, BS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 DELAFIELD ST SUITE 15
WAUKESHA WI
53188-3417
US

IV. Provider business mailing address

1300 N 116TH ST APT. 3
WAUWATOSA WI
53226-3262
US

V. Phone/Fax

Practice location:
  • Phone: 262-521-9762
  • Fax: 262-521-1091
Mailing address:
  • Phone: 414-324-4172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number657-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: