=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558769125
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID KROLL MA.ED., ATC/L
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2014
-----------------------------------------------------
Last Update Date | 12/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | BALKNAP & CATLIN AVES.
-----------------------------------------------------
City | SUPERIOR
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54880
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-394-8144
-----------------------------------------------------
Fax | 715-395-4643
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1628 LAMBORN AVE
-----------------------------------------------------
City | SUPERIOR
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54880-2824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-919-1816
-----------------------------------------------------
Fax | 715-395-4636
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 486-39
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------