Provider Demographics
NPI:1396904454
Name:RADLOFF, MARCIA K (LAC, MSOM)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:K
Last Name:RADLOFF
Suffix:
Gender:F
Credentials:LAC, MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-3874
Mailing Address - Country:US
Mailing Address - Phone:920-261-6999
Mailing Address - Fax:920-261-6966
Practice Address - Street 1:621 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-3874
Practice Address - Country:US
Practice Address - Phone:920-261-6999
Practice Address - Fax:920-261-6966
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-04
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI528-055171100000X, 133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI528055OtherSTATE LICENSE NUMBER