Healthcare Provider Details

I. General information

NPI: 1730796509
Provider Name (Legal Business Name): ZACHARY TAVS LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 W PARADISE DR
WEST BEND WI
53095-9795
US

IV. Provider business mailing address

1700 W PARADISE DR
WEST BEND WI
53095-9795
US

V. Phone/Fax

Practice location:
  • Phone: 262-334-3451
  • Fax: 262-347-3054
Mailing address:
  • Phone: 262-334-3451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1519-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: