=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700860418
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROY J EGGART PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2005
-----------------------------------------------------
Last Update Date | 01/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 520 AMY DR
-----------------------------------------------------
City | HOLMEN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54636-9337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-526-3351
-----------------------------------------------------
Fax | 608-526-3412
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 WEST AVE S
-----------------------------------------------------
City | LA CROSSE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54601-4783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-791-4156
-----------------------------------------------------
Fax | 608-791-9898
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 973
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------