=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356434526
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENT DAVID KOWALKE D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2006
-----------------------------------------------------
Last Update Date | 12/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1468 N HIGH POINT RD
-----------------------------------------------------
City | MIDDLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53562-3683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-833-7422
-----------------------------------------------------
Fax | 608-833-7421
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1468 N HIGH POINT RD
-----------------------------------------------------
City | MIDDLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53562-3683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-833-7422
-----------------------------------------------------
Fax | 608-833-7421
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4240012
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------