1306335385 NPI number — SAMUEL LAWRENCE KONRATH ATC, LAT

Table of content: SAMUEL LAWRENCE KONRATH ATC, LAT (NPI 1306335385)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306335385 NPI number — SAMUEL LAWRENCE KONRATH ATC, LAT

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
KONRATH

Provider First Name:
SAMUEL

Provider Middle Name:
LAWRENCE

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:
ATC, LAT

Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306335385

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
10/14/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
503 BROADWAY ST S APT 403

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
MENOMONIE

Provider Business Mailing Address State Name:
WI

Provider Business Mailing Address Postal Code:
54751-3095

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
414-573-6009

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
712 BROADWAY ST S

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
MENOMONIE

Provider Business Practice Location Address State Name:
WI

Provider Business Practice Location Address Postal Code:
54751-2458

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
414-573-6009

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
05/06/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Taxonomy code: 2255A2300X , with the licence number: 2466 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .