Provider Demographics
NPI:1275755092
Name:BROADWAY CHIROPRACTIC CLINIC PC
Entity Type:Organization
Organization Name:BROADWAY CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:ROGGE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:712-322-8504
Mailing Address - Street 1:103 N AVENUE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503
Mailing Address - Country:US
Mailing Address - Phone:712-322-8504
Mailing Address - Fax:402-614-5823
Practice Address - Street 1:103 N AVENUE
Practice Address - Street 2:SUITE 4
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503
Practice Address - Country:US
Practice Address - Phone:712-322-8504
Practice Address - Fax:402-614-5823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04972111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA20218Medicare ID - Type Unspecified