Provider Demographics
NPI:1346445616
Name:BROUSSARD, BURT JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:BURT
Middle Name:JOSEPH
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 2ND ST
Mailing Address - Street 2:SUITE I
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-2299
Mailing Address - Country:US
Mailing Address - Phone:925-634-6161
Mailing Address - Fax:925-634-0222
Practice Address - Street 1:1185 2ND ST
Practice Address - Street 2:SUITE I
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-2299
Practice Address - Country:US
Practice Address - Phone:925-634-6161
Practice Address - Fax:925-634-0222
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC15731111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor