Provider Demographics
NPI:1174933105
Name:BUSH, MARA (DC)
Entity type:Individual
Prefix:DR
First Name:MARA
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9066 PALOMINO RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-5806
Mailing Address - Country:US
Mailing Address - Phone:619-938-1024
Mailing Address - Fax:619-258-9738
Practice Address - Street 1:7596 EADS AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-4851
Practice Address - Country:US
Practice Address - Phone:858-456-2663
Practice Address - Fax:858-456-9925
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11558111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor