Provider Demographics
NPI:1578181657
Name:SCHOCK, BRODEN (AT)
Entity Type:Individual
Prefix:
First Name:BRODEN
Middle Name:
Last Name:SCHOCK
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 85TH AVE
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001-4947
Mailing Address - Country:US
Mailing Address - Phone:715-557-1086
Mailing Address - Fax:
Practice Address - Street 1:220 KELLER AVE N
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001-1036
Practice Address - Country:US
Practice Address - Phone:715-268-1008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2168-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer