Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | G36509 | CA |
NPI | 1003852815 |
---|---|
Provider Name | Louis Brenner |
First Address | Upland, CA 91786-2800 |
Second Address | Upland, CA 91786-2800 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A46711 | (02) | CA |