Provider Demographics
NPI:1689162950
Name:BRONK DC, BRIAN (DC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BRONK DC
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 1:1101 OCEAN FRONT WALK APT 202
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-9025
Mailing Address - Country:US
Mailing Address - Phone:310-828-4608
Mailing Address - Fax:
Practice Address - Street 1:1101 OCEAN FRONT WALK APT 202
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-9025
Practice Address - Country:US
Practice Address - Phone:310-828-4608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17028111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty