Provider Demographics
NPI:1417053828
Name:ANDERSON, RENATA M (DC)
Entity Type:Individual
Prefix:
First Name:RENATA
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:RENATA
Other - Middle Name:M
Other - Last Name:BELLIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:415 W WISCONSIN ST
Mailing Address - Street 2:STE 4
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-2492
Mailing Address - Country:US
Mailing Address - Phone:608-269-4511
Mailing Address - Fax:608-269-8511
Practice Address - Street 1:559 BRAUND ST
Practice Address - Street 2:STE 3
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8658
Practice Address - Country:US
Practice Address - Phone:608-783-7735
Practice Address - Fax:608-783-7762
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3615-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI350050305OtherRAILROAD MEDICARE
WI38924400Medicaid
CB3715OtherRAILROAD MEDICARE GROUP
WIK400173470Medicare PIN
WI350050305OtherRAILROAD MEDICARE