Provider Demographics
NPI:1184024937
Name:BROADWAY PLAZA PAIN RELIEF CENTER
Entity Type:Organization
Organization Name:BROADWAY PLAZA PAIN RELIEF CENTER
Other - Org Name:HALL CHIROPRACTIC PAIN RELIEF CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:219-924-2112
Mailing Address - Street 1:801 W GLEN PARK AVE
Mailing Address - Street 2:
Mailing Address - City:GRIFFITH
Mailing Address - State:IN
Mailing Address - Zip Code:46319-2087
Mailing Address - Country:US
Mailing Address - Phone:219-924-2112
Mailing Address - Fax:219-924-2114
Practice Address - Street 1:801 W GLEN PARK AVE
Practice Address - Street 2:
Practice Address - City:GRIFFITH
Practice Address - State:IN
Practice Address - Zip Code:46319-2087
Practice Address - Country:US
Practice Address - Phone:219-924-2112
Practice Address - Fax:219-924-2114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001395A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100338150Medicaid
IN100338150Medicaid
IN405430Medicare PIN