Provider Demographics
NPI:1619909546
Name:BRUNKHORST, DANIEL EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:EDWARD
Last Name:BRUNKHORST
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 1:742 N MARKET ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1079
Mailing Address - Country:US
Mailing Address - Phone:618-939-9850
Mailing Address - Fax:618-939-9860
Practice Address - Street 1:742 N MARKET ST
Practice Address - Street 2:SUITE D
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1079
Practice Address - Country:US
Practice Address - Phone:618-939-9850
Practice Address - Fax:618-939-9860
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010170111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209846Medicare ID - Type UnspecifiedCHIROPRACTOR
ILV01395Medicare UPIN