Provider Demographics
NPI:1265837744
Name:BRENNECKE, MATTHEW (ND)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:BRENNECKE
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 PATTERSON CT
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-4254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1121 W PROSPECT RD
Practice Address - Street 2:SUITE B
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-5623
Practice Address - Country:US
Practice Address - Phone:970-294-1977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-27
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000087175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath