Provider Demographics
NPI:1871925669
Name:PAULSON, BRENT RICHARD (DC)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:RICHARD
Last Name:PAULSON
Suffix:
Gender:M
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 96
Mailing Address - Street 2:
Mailing Address - City:CLEAR LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54005-0096
Mailing Address - Country:US
Mailing Address - Phone:715-263-2313
Mailing Address - Fax:715-263-3284
Practice Address - Street 1:336 3RD AVE
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:WI
Practice Address - Zip Code:54005-8581
Practice Address - Country:US
Practice Address - Phone:715-263-2313
Practice Address - Fax:715-263-3284
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4949-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor