1972375004 NPI number — DR. RAYMOND EDWARD BRENNICK III DPT

Table of content: DR. RAYMOND EDWARD BRENNICK III DPT (NPI 1972375004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972375004 NPI number — DR. RAYMOND EDWARD BRENNICK III DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRENNICK
Provider First Name:
RAYMOND
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
DPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRENNICK
Provider Other First Name:
NED
Provider Other Middle Name:
EDWARD
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
III
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1972375004
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
637 MOSS PARK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KISSIMMEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34743-6130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
46 NICHOLS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUTLAND
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05701-3275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-775-2941
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  040.0134641 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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