Provider Demographics
NPI:1700928017
Name:BROTOLOC OUTPATIENT CLINIC
Entity Type:Organization
Organization Name:BROTOLOC OUTPATIENT CLINIC
Other - Org Name:BROTOLOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SVEDA
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:414-543-3200
Mailing Address - Street 1:5812 WEST BURNHAM STREET
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53219
Mailing Address - Country:US
Mailing Address - Phone:414-543-3200
Mailing Address - Fax:414-543-3269
Practice Address - Street 1:5812 W BURNHAM ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53219-1524
Practice Address - Country:US
Practice Address - Phone:414-543-3200
Practice Address - Fax:414-543-3269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1114261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42207400Medicaid
WI42207400Medicaid