Provider Demographics
NPI:1528176773
Name:BRENNER, CHARLES M III (DC)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:M
Last Name:BRENNER
Suffix:III
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4142 S HARVARD
Mailing Address - Street 2:SUITE D 2
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2617
Mailing Address - Country:US
Mailing Address - Phone:918-745-9123
Mailing Address - Fax:918-712-7457
Practice Address - Street 1:4142 S HARVARD
Practice Address - Street 2:SUITE D 2
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2617
Practice Address - Country:US
Practice Address - Phone:918-745-9123
Practice Address - Fax:918-712-7457
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1763111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731192722001OtherBCBS
OK731192722001OtherBCBS