Healthcare Provider Details

I. General information

NPI: 1275878308
Provider Name (Legal Business Name): BRANDON LEE BOOTHE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2012
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7645 E EVANS RD STE 140
SCOTTSDALE AZ
85260-3492
US

IV. Provider business mailing address

7645 E EVANS RD STE 140
SCOTTSDALE AZ
85260-3492
US

V. Phone/Fax

Practice location:
  • Phone: 408-598-6219
  • Fax:
Mailing address:
  • Phone: 408-598-6219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number32126
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: