Healthcare Provider Details

I. General information

NPI: 1457302374
Provider Name (Legal Business Name): BRENT DAVID LEININGER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 06/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MAIN ST
WANAMINGO MN
55983-3848
US

IV. Provider business mailing address

PO BOX 214
WANAMINGO MN
55983-0214
US

V. Phone/Fax

Practice location:
  • Phone: 507-824-2336
  • Fax:
Mailing address:
  • Phone: 507-824-2336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4210-012
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4846
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: