Healthcare Provider Details

I. General information

NPI: 1033518162
Provider Name (Legal Business Name): EAN VAN VLIET
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 WEST MONROE STREET
WYOCENA WI
53969
US

IV. Provider business mailing address

5162 ANTON DR APT 301
FITCHBURG WI
53719-1716
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1945
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: