Provider Demographics
NPI:1184028490
Name:BRODERICK CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:BRODERICK CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRODERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-264-4151
Mailing Address - Street 1:1424 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-3404
Mailing Address - Country:US
Mailing Address - Phone:574-264-4151
Mailing Address - Fax:574-262-9891
Practice Address - Street 1:1424 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-3404
Practice Address - Country:US
Practice Address - Phone:574-264-4151
Practice Address - Fax:574-262-9891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000723A111N00000X
IN08000306A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100112520AMedicaid
IN100203690AMedicaid
IN000000084724OtherBLUE CROSS
IN000000112128OtherBLUE CROSS
IN000000112128OtherBLUE CROSS
IN100112520AMedicaid
IN000000084724OtherBLUE CROSS
INU29275Medicare UPIN