Provider Demographics
NPI:1467074401
Name:GENENBACHER, BRETT
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:GENENBACHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1362 N 1403RD LN
Mailing Address - Street 2:
Mailing Address - City:FOWLER
Mailing Address - State:IL
Mailing Address - Zip Code:62338-2118
Mailing Address - Country:US
Mailing Address - Phone:217-779-6698
Mailing Address - Fax:
Practice Address - Street 1:1362 N 1403RD LN
Practice Address - Street 2:
Practice Address - City:FOWLER
Practice Address - State:IL
Practice Address - Zip Code:62338-2118
Practice Address - Country:US
Practice Address - Phone:217-779-6698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program