Provider Demographics
NPI:1265816342
Name:ADVANCED MOVEMENT STUDIO
Entity Type:Organization
Organization Name:ADVANCED MOVEMENT STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER, ATHLETIC TRAINER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRAUN
Authorized Official - Suffix:
Authorized Official - Credentials:LAT, CSCS, CES
Authorized Official - Phone:920-209-1662
Mailing Address - Street 1:101 W EDISON AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-1367
Mailing Address - Country:US
Mailing Address - Phone:920-209-1662
Mailing Address - Fax:
Practice Address - Street 1:101 W EDISON AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1367
Practice Address - Country:US
Practice Address - Phone:920-209-1662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1145-39261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty