Provider Demographics
NPI:1407185325
Name:BROTOLOC SOUTH, INC.
Entity Type:Organization
Organization Name:BROTOLOC SOUTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHNEIDER
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:262-473-0484
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:262-473-0484
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROTOLOC SOUTH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-24
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1115261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42181100Medicaid
WI42181100Medicaid