Healthcare Provider Details

I. General information

NPI: 1386191799
Provider Name (Legal Business Name): DALLAS ROGER LOUKES PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 W MONROE ST
WYOCENA WI
53969
US

IV. Provider business mailing address

315 VALLEY VIEW DR
RIO WI
53960-8037
US

V. Phone/Fax

Practice location:
  • Phone: 608-429-2181
  • Fax:
Mailing address:
  • Phone: 218-591-2606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2335-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: