Provider Demographics
NPI:1457302374
Name:LEININGER, BRENT DAVID (DC)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:DAVID
Last Name:LEININGER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 214
Mailing Address - Street 2:
Mailing Address - City:WANAMINGO
Mailing Address - State:MN
Mailing Address - Zip Code:55983-0214
Mailing Address - Country:US
Mailing Address - Phone:507-824-2336
Mailing Address - Fax:
Practice Address - Street 1:200 MAIN ST
Practice Address - Street 2:
Practice Address - City:WANAMINGO
Practice Address - State:MN
Practice Address - Zip Code:55983-3848
Practice Address - Country:US
Practice Address - Phone:507-824-2336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4210-012111N00000X
MN4846111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN428319800Medicaid
MN428319800Medicaid
MN350003664Medicare ID - Type Unspecified
MN350003664Medicare PIN
MNC03302Medicare PIN