Healthcare Provider Details

I. General information

NPI: 1669943114
Provider Name (Legal Business Name): MICHAEL KLAVER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2018
Last Update Date: 12/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 W WATERTOWN PLANK RD
WAUWATOSA WI
53226-3595
US

IV. Provider business mailing address

8700 W WATERTOWN PLANK RD
WAUWATOSA WI
53226-3595
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-7111
  • Fax:
Mailing address:
  • Phone: 414-805-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1904-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: