Provider Demographics
NPI:1063862134
Name:COFFMAN, BRENT (DC)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:
Last Name:COFFMAN
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 1:1601 CARMEN DR STE 112
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-3100
Mailing Address - Country:US
Mailing Address - Phone:805-383-9114
Mailing Address - Fax:
Practice Address - Street 1:1601 CARMEN DR STE 112
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-3100
Practice Address - Country:US
Practice Address - Phone:805-383-9114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33609111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor