Provider Demographics
NPI:1316953078
Name:KLUSENDORF, BRYAN J (DC)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:J
Last Name:KLUSENDORF
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 E EVERGREEN DR
Mailing Address - Street 2:STE A
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8910
Mailing Address - Country:US
Mailing Address - Phone:920-735-0773
Mailing Address - Fax:920-735-0293
Practice Address - Street 1:2505 E EVERGREEN DR
Practice Address - Street 2:STE A
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8910
Practice Address - Country:US
Practice Address - Phone:920-735-0773
Practice Address - Fax:920-735-0293
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1690111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT62440Medicare ID - Type Unspecified
WI000035494Medicare ID - Type Unspecified
T62440Medicare UPIN