Provider Demographics
NPI:1558485375
Name:BERLENER, BRENT RAY (D C)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:RAY
Last Name:BERLENER
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3216 EMERALD LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-6947
Mailing Address - Country:US
Mailing Address - Phone:573-636-6400
Mailing Address - Fax:573-636-6401
Practice Address - Street 1:3216 EMERALD LN
Practice Address - Street 2:SUITE A
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6947
Practice Address - Country:US
Practice Address - Phone:573-636-6400
Practice Address - Fax:573-636-6401
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006010204111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2006010204OtherMISSOURI LICENSE NO.