Healthcare Provider Details

I. General information

NPI: 1588703110
Provider Name (Legal Business Name): BRANT L GERCKENS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 02/02/2016
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 Code111NN1001X
TaxonomyNutrition Chiropractor
License Number14605
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: