Provider Demographics
NPI:1205846920
Name:BROUSSARD CLINIC OF CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:BROUSSARD CLINIC OF CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:ALEXIS
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:806-796-0098
Mailing Address - Street 1:6701 ABERDEEN AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-1519
Mailing Address - Country:US
Mailing Address - Phone:806-796-0098
Mailing Address - Fax:806-796-0976
Practice Address - Street 1:6701 ABERDEEN AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-1519
Practice Address - Country:US
Practice Address - Phone:806-796-0098
Practice Address - Fax:806-796-0976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4880111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00775RMedicare ID - Type UnspecifiedMEDICARE PROVIDER (GROUP)