Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 14605 | CA |
NPI | 1588703110 |
---|---|
Provider Name | Brant L Gerckens |
First Address | Ventura, CA 93003-5357 |
Second Address | Ventura, CA 93003-5357 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/02/2007 |
Last Update Date | 02/02/2016 |