Provider Demographics
NPI:1215900238
Name:ROTTACKER, RUSSELL BRADLEY (DC)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:BRADLEY
Last Name:ROTTACKER
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 1:321 N. MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336
Mailing Address - Country:US
Mailing Address - Phone:209-824-8160
Mailing Address - Fax:209-824-8391
Practice Address - Street 1:321 N. MAIN ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336
Practice Address - Country:US
Practice Address - Phone:209-824-8160
Practice Address - Fax:209-824-8391
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15553111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT05811Medicare UPIN
CADC0155530Medicare ID - Type Unspecified