Provider Demographics
NPI:1417576794
Name:BROSCHAT, CALEB ADAM
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:ADAM
Last Name:BROSCHAT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2983 LILY PL
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-5433
Mailing Address - Country:US
Mailing Address - Phone:707-272-9702
Mailing Address - Fax:
Practice Address - Street 1:10535 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:MATHER
Practice Address - State:CA
Practice Address - Zip Code:95655-4200
Practice Address - Country:US
Practice Address - Phone:916-843-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86072165133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered