Provider Demographics
NPI:1386774784
Name:MIELCAREK, ANTHONY CHRISTOPHER (PTA)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:CHRISTOPHER
Last Name:MIELCAREK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-3846
Mailing Address - Country:US
Mailing Address - Phone:262-633-6069
Mailing Address - Fax:262-656-3315
Practice Address - Street 1:801 SOUTH ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-3846
Practice Address - Country:US
Practice Address - Phone:262-633-6069
Practice Address - Fax:262-656-3315
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI636-019282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital