Healthcare Provider Details

I. General information

NPI: 1356709372
Provider Name (Legal Business Name): GERCKENS CHIROPRACTIC AND WELLNESS CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S VICTORIA AVE STE 100
VENTURA CA
93003-5357
US

IV. Provider business mailing address

801 S VICTORIA AVE STE 100
VENTURA CA
93003-5357
US

V. Phone/Fax

Practice location:
  • Phone: 805-644-0460
  • Fax: 805-644-0465
Mailing address:
  • Phone: 805-644-0460
  • Fax: 805-644-0465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number14605
License Number StateCA

VIII. Authorized Official

Name: DR. BRANT L. GERCKENS
Title or Position: PRESIDENT
Credential: D.C.
Phone: 805-644-0460