Provider Demographics
NPI:1013092162
Name:BRENNER, MARK ANTHONY (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:BRENNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2380 TROOP DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-4637
Mailing Address - Country:US
Mailing Address - Phone:320-252-5599
Mailing Address - Fax:320-253-4585
Practice Address - Street 1:2380 TROOP DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-4637
Practice Address - Country:US
Practice Address - Phone:320-252-5599
Practice Address - Fax:320-253-4585
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN2229111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN26817BROtherBLUECROSS/BLUE SHIELD
MN808328200Medicaid
MN26817BROtherBLUECROSS/BLUE SHIELD