Provider Demographics
NPI:1982933503
Name:BROTOLOC SOUTH, INC.
Entity Type:Organization
Organization Name:BROTOLOC SOUTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:E
Authorized Official - Last Name:SVEDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-543-3200
Mailing Address - Street 1:5812 W BURNHAM ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53219-1524
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?:Yes
Parent Organization LBN:BROTOLOC SOUTH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-10
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42207400Medicaid
WI000088208Medicare PIN