Provider Demographics
NPI:1588777254
Name:FORTIN, BRENDA KAREN (DC)
Entity type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:KAREN
Last Name:FORTIN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 271
Mailing Address - Street 2:
Mailing Address - City:HAMEL
Mailing Address - State:MN
Mailing Address - Zip Code:55340-0271
Mailing Address - Country:US
Mailing Address - Phone:763-478-3978
Mailing Address - Fax:763-478-3502
Practice Address - Street 1:75 HAMEL RD
Practice Address - Street 2:
Practice Address - City:HAMEL
Practice Address - State:MN
Practice Address - Zip Code:55340-4567
Practice Address - Country:US
Practice Address - Phone:763-478-3978
Practice Address - Fax:763-478-3502
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2014-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4147111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN08154FOOtherBCBS GROUP/CLINIC
MN081G5FOOtherBCBS INDIVIDUAL
MN115092800Medicaid
MNU91171Medicare UPIN
MN081G5FOOtherBCBS INDIVIDUAL
MN350003182Medicare ID - Type UnspecifiedINDIVDUAL