Provider Demographics
NPI:1831633882
Name:RENNICKER, BRANDON LEE (DC)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:LEE
Last Name:RENNICKER
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 1:10007 ELTON ST SW
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:OH
Mailing Address - Zip Code:44662-8731
Mailing Address - Country:US
Mailing Address - Phone:740-227-0293
Mailing Address - Fax:
Practice Address - Street 1:1042 TUSCARAWAS AVE NW
Practice Address - Street 2:
Practice Address - City:NEW PHILADELPHIA
Practice Address - State:OH
Practice Address - Zip Code:44663-1025
Practice Address - Country:US
Practice Address - Phone:330-364-3933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-10
Last Update Date:2016-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4672111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor