MEDICARE: LESLIE A. MROCH RN

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	163W00000X	Registered Nurse		WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881628295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE A. MROCH RN

Provider Business Mailing Address
First Line	:	PO BOX 103
Second Line	:
City	:	EAST TROY
State	:	WI
Zip	:	53120-0103
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	NORTH 9351 ADAMS ROAD
Second Line	:
City	:	EAST TROY
State	:	WI
Zip	:	53120-0103
Country	:	US
Telephone Number	:	262-495-3676
Fax Number	:

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

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	07/08/2007

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