MEDICARE: BREANNA JUNE DOROTHY D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	4625-012	WI
2	111N00000X	Chiropractor	6042	MN

General Provider Information

NPI Number	:	1215258850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BREANNA JUNE DOROTHY D.C.

Provider Business Mailing Address
First Line	:	5436 209TH LN NE
Second Line	:
City	:	WYOMING
State	:	MN
Zip	:	55092-9474
Country	:	US
Telephone Number	:	920-203-6562
Fax Number	:	920-982-6461

Provider Business Practice Location Address
First Line	:	6041 MAIN ST STE E
Second Line	:
City	:	NORTH BRANCH
State	:	MN
Zip	:	55056-6595
Country	:	US
Telephone Number	:	651-674-5040
Fax Number	:	920-982-6461

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2010
Last Update Date	:	05/23/2019

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