Provider Demographics
NPI:1083841860
Name:REILLY, BROGHAN JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:BROGHAN
Middle Name:JAMES
Last Name:REILLY
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 1:4751 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-2752
Mailing Address - Country:US
Mailing Address - Phone:715-723-2892
Mailing Address - Fax:715-723-3540
Practice Address - Street 1:3032 COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-5078
Practice Address - Country:US
Practice Address - Phone:715-723-2892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4512-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor