Provider Demographics
NPI:1184841660
Name:BROTOLOC INC. OUTPATIENT CLINIC
Entity Type:Organization
Organization Name:BROTOLOC INC. OUTPATIENT CLINIC
Other - Org Name:BROTOLOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:S
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-473-0480
Mailing Address - Street 1:209 S TAFT ST
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-2139
Mailing Address - Country:US
Mailing Address - Phone:262-473-0480
Mailing Address - Fax:262-473-0486
Practice Address - Street 1:209 S TAFT ST
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-2139
Practice Address - Country:US
Practice Address - Phone:262-473-0480
Practice Address - Fax:262-473-0486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1115103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42181100Medicaid
WI65180Medicare ID - Type Unspecified