Provider Demographics
NPI:1457458093
Name:BRODY, BRUCE K (DC)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:K
Last Name:BRODY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:19231 VICTORY BLVD
Mailing Address - Street 2:SUITE 352
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-6308
Mailing Address - Country:US
Mailing Address - Phone:818-705-0184
Mailing Address - Fax:818-705-0576
Practice Address - Street 1:19231 VICTORY BLVD
Practice Address - Street 2:SUITE 352
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-6308
Practice Address - Country:US
Practice Address - Phone:818-705-0184
Practice Address - Fax:818-705-0576
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CADC 20925111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU65657Medicare UPIN