MEDICARE: MRS. ALICIA MARIE BRUDER LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor	12453-146	WI

General Provider Information

NPI Number	:	1487066338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALICIA MARIE BRUDER LMT

Provider Business Mailing Address
First Line	:	219 RIVER AVE S
Second Line	:	P.O. BOX 65
City	:	PRAIRIE FARM
State	:	WI
Zip	:	54762-9786
Country	:	US
Telephone Number	:	715-455-1166
Fax Number	:

Provider Business Practice Location Address
First Line	:	219 RIVER AVE S
Second Line	:
City	:	PRAIRIE FARM
State	:	WI
Zip	:	54762-9786
Country	:	US
Telephone Number	:	715-455-1166
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2014
Last Update Date	:	05/27/2014

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