Provider Demographics
NPI:1164509816
Name:BROADWAY CHIROPRACTIC CLINIC, PC
Entity Type:Organization
Organization Name:BROADWAY CHIROPRACTIC CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:WAFFUL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:210-828-4422
Mailing Address - Street 1:7870 BROADWAY ST # C-100
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-2561
Mailing Address - Country:US
Mailing Address - Phone:210-828-4422
Mailing Address - Fax:
Practice Address - Street 1:7870 BROADWAY ST # C-100
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-2561
Practice Address - Country:US
Practice Address - Phone:210-828-4422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4563111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty