Provider Demographics
NPI:1457446528
Name:LAUE, BRENDA GRICE (DC)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:GRICE
Last Name:LAUE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MS
Other - First Name:BRENDA
Other - Middle Name:JEAN
Other - Last Name:GRICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1423 IDLEWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-1418
Mailing Address - Country:US
Mailing Address - Phone:818-242-5527
Mailing Address - Fax:818-246-9190
Practice Address - Street 1:230 N MARYLAND AVE STE 103
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4283
Practice Address - Country:US
Practice Address - Phone:818-391-8955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17165111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC17165Medicare ID - Type Unspecified