Provider Demographics
NPI:1114142411
Name:BROVOLD, CLAYTON IRWIN (DC)
Entity Type:Individual
Prefix:DR
First Name:CLAYTON
Middle Name:IRWIN
Last Name:BROVOLD
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 1:49665 US HIGHWAY 93
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-2301
Mailing Address - Country:US
Mailing Address - Phone:406-883-4234
Mailing Address - Fax:406-883-4297
Practice Address - Street 1:49665 US HIGHWAY 93
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-2301
Practice Address - Country:US
Practice Address - Phone:406-883-4234
Practice Address - Fax:406-883-4297
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT392111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000166244Medicaid
MT0000166243Medicaid
MT0000166243Medicaid
MT000004079Medicare PIN