Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 10968 | WI |
NPI | 1003084005 |
---|---|
Provider Name | Mr. Brent Bode |
First Address | Pewaukee, WI 53072-3790 |
Second Address | Milwaukee, WI 53202-8150 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/02/2008 |
Last Update Date | 03/08/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
001182625 | (02) | WI |
361161700 | (05) | WI |
APPLIED FOR | ALL NUMBERS APPLIED FOR (01) | WI |