Provider Demographics
NPI:1811455462
Name:KOMLOFSKE, BRENT P (ATC, LAT)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:P
Last Name:KOMLOFSKE
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 N IBP RD
Mailing Address - Street 2:
Mailing Address - City:HOLCOMB
Mailing Address - State:KS
Mailing Address - Zip Code:67851-9023
Mailing Address - Country:US
Mailing Address - Phone:620-640-7924
Mailing Address - Fax:
Practice Address - Street 1:1008 JERRY MASHEK DR
Practice Address - Street 2:
Practice Address - City:WEST
Practice Address - State:TX
Practice Address - Zip Code:76691-1866
Practice Address - Country:US
Practice Address - Phone:254-981-2050
Practice Address - Fax:254-826-7514
Is Sole Proprietor?:No
Enumeration Date:2019-03-03
Last Update Date:2019-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT72332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer