Provider Demographics
NPI:1063106391
Name:FOOTE, BRAD (DC)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:FOOTE
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 1:4820 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6917
Mailing Address - Country:US
Mailing Address - Phone:310-392-7889
Mailing Address - Fax:
Practice Address - Street 1:4820 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6917
Practice Address - Country:US
Practice Address - Phone:310-392-7889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36176111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor