Provider Demographics
NPI:1538211537
Name:JAMES A. BROSTROM
Entity type:Organization
Organization Name:JAMES A. BROSTROM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-896-9661
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53187-0338
Mailing Address - Country:US
Mailing Address - Phone:262-896-9661
Mailing Address - Fax:262-896-9662
Practice Address - Street 1:1900 LAURA LN
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-2808
Practice Address - Country:US
Practice Address - Phone:262-896-9661
Practice Address - Fax:262-896-9662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14650174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty