Provider Demographics
NPI:1831407063
Name:RENQUIST, BRETT (DC, LAC)
Entity type:Individual
Prefix:DR
First Name:BRETT
Middle Name:
Last Name:RENQUIST
Suffix:
Gender:M
Credentials:DC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1095 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4140
Mailing Address - Country:US
Mailing Address - Phone:503-585-1282
Mailing Address - Fax:503-585-5531
Practice Address - Street 1:1095 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4140
Practice Address - Country:US
Practice Address - Phone:503-585-1282
Practice Address - Fax:503-585-5531
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-22
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4042111N00000X
ORAC153703171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist