Provider Demographics
NPI:1902000979
Name:PEDERSEN, BRANT (DC)
Entity Type:Individual
Prefix:
First Name:BRANT
Middle Name:
Last Name:PEDERSEN
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 1:15951 LOS GATOS BLVD.
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-3428
Mailing Address - Country:US
Mailing Address - Phone:408-358-5086
Mailing Address - Fax:408-358-5099
Practice Address - Street 1:15951 LOS GATOS BLVD.
Practice Address - Street 2:SUITE 3
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-3428
Practice Address - Country:US
Practice Address - Phone:408-358-5086
Practice Address - Fax:408-358-5099
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-29419111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV05582Medicare UPIN
CADC0294190Medicare ID - Type UnspecifiedPART B - NON-PAR