Provider Demographics
NPI:1932242823
Name:KLENK, BRODIE I (DC)
Entity Type:Individual
Prefix:
First Name:BRODIE
Middle Name:I
Last Name:KLENK
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 1:5409 17TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-3818
Mailing Address - Country:US
Mailing Address - Phone:206-784-3895
Mailing Address - Fax:206-784-7471
Practice Address - Street 1:5409 17TH AVE NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-3818
Practice Address - Country:US
Practice Address - Phone:206-784-3895
Practice Address - Fax:206-784-7471
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034175111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8857090Medicare ID - Type Unspecified