Provider Demographics
NPI:1326557828
Name:BRODERICK CHIROPRACTIC CORPORATION
Entity Type:Organization
Organization Name:BRODERICK CHIROPRACTIC CORPORATION
Other - Org Name:LIFE CHOICE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:MARGRET WEBER
Authorized Official - Last Name:BRODERICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:562-420-5433
Mailing Address - Street 1:3816 WOODRUFF AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-2145
Mailing Address - Country:US
Mailing Address - Phone:562-420-5433
Mailing Address - Fax:
Practice Address - Street 1:3816 WOODRUFF AVE STE 202
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-2145
Practice Address - Country:US
Practice Address - Phone:562-420-5433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC30736261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
1356539571OtherINDIVIDUAL NPI