Provider Demographics
NPI:1366456709
Name:BLAIR CHIROPRACTIC CENTER, LLC
Entity Type:Organization
Organization Name:BLAIR CHIROPRACTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BROST
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-989-2020
Mailing Address - Street 1:PO BOX 66
Mailing Address - Street 2:
Mailing Address - City:BLAIR
Mailing Address - State:WI
Mailing Address - Zip Code:54616-0066
Mailing Address - Country:US
Mailing Address - Phone:608-989-2020
Mailing Address - Fax:608-989-2308
Practice Address - Street 1:237 W. BROADWAY
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:WI
Practice Address - Zip Code:54616
Practice Address - Country:US
Practice Address - Phone:608-989-2020
Practice Address - Fax:608-989-2308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3358-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU62936Medicare UPIN