Provider Demographics
NPI:1346454071
Name:CHIROPRACTIC CARE OF VICTOR VALLEY
Entity Type:Organization
Organization Name:CHIROPRACTIC CARE OF VICTOR VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DR OF CHIROPRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:G
Authorized Official - Last Name:BROUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:760-946-4619
Mailing Address - Street 1:95 ARGONAUT
Mailing Address - Street 2:280
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-4133
Mailing Address - Country:US
Mailing Address - Phone:949-598-9999
Mailing Address - Fax:949-598-9990
Practice Address - Street 1:18484 US HIGHWAY 18
Practice Address - Street 2:280B
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2375
Practice Address - Country:US
Practice Address - Phone:760-946-4619
Practice Address - Fax:760-946-2360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC14559111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0145590OtherBLUE SHIELD
CAT05425Medicare UPIN
CADC0145590Medicare ID - Type Unspecified