Provider Demographics
NPI:1780919753
Name:LIGHTFOOT, KHADIJAH (DC)
Entity type:Individual
Prefix:DR
First Name:KHADIJAH
Middle Name:
Last Name:LIGHTFOOT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 SAN PABLO AVE
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-3804
Mailing Address - Country:US
Mailing Address - Phone:510-918-8574
Mailing Address - Fax:510-969-8801
Practice Address - Street 1:3811 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-3804
Practice Address - Country:US
Practice Address - Phone:510-918-8574
Practice Address - Fax:510-969-8801
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-08
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31404111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor