Healthcare Provider Details

I. General information

NPI: 1245638584
Provider Name (Legal Business Name): THE RENNEKE CHIROPRACTIC CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2014
Last Update Date: 02/28/2021
Certification Date: 02/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 MADISON ST.
BRAINERD MN
56401
US

IV. Provider business mailing address

623 MADISON ST
BRAINERD MN
56401
US

V. Phone/Fax

Practice location:
  • Phone: 218-829-5380
  • Fax: 218-825-0972
Mailing address:
  • Phone: 218-829-5380
  • Fax: 218-825-0972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1572
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5809
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateMN

VIII. Authorized Official

Name: DR. DEAN GLENN RENNEKE
Title or Position: PRES
Credential: DC
Phone: 218-829-5380