Provider Demographics
NPI:1619921210
Name:DEAN G RENNEKE, DC, PA
Entity Type:Organization
Organization Name:DEAN G RENNEKE, DC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:RENNEKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-829-5380
Mailing Address - Street 1:623 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-4518
Mailing Address - Country:US
Mailing Address - Phone:218-829-5380
Mailing Address - Fax:218-825-0972
Practice Address - Street 1:623 MADISON ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-4518
Practice Address - Country:US
Practice Address - Phone:218-829-5380
Practice Address - Fax:218-825-0972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN183111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN52777REOtherBLUE CROSS BLUE SHIELD
MN52777REOtherBLUE CROSS BLUE SHIELD