Provider Demographics
NPI:1245309327
Name:BREIDENBACH, BENJAMIN JOHN
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOHN
Last Name:BREIDENBACH
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:N5498 HWY 35
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650
Mailing Address - Country:US
Mailing Address - Phone:608-779-5323
Mailing Address - Fax:608-779-5328
Practice Address - Street 1:1640 GEORGE ST
Practice Address - Street 2:
Practice Address - City:LACROSSE
Practice Address - State:WI
Practice Address - Zip Code:54650
Practice Address - Country:US
Practice Address - Phone:608-781-9880
Practice Address - Fax:608-783-5426
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3676012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38927000Medicaid
U81343Medicare UPIN
WI38927000Medicaid