Provider Demographics
NPI:1467626333
Name:BROAD STREET CHIROPRACTIC CLINIC INC
Entity Type:Organization
Organization Name:BROAD STREET CHIROPRACTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:614-251-0222
Mailing Address - Street 1:899 E BROAD ST STE 425
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-1195
Mailing Address - Country:US
Mailing Address - Phone:614-251-0222
Mailing Address - Fax:614-251-0258
Practice Address - Street 1:899 E BROAD ST
Practice Address - Street 2:SUITE 425
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-1156
Practice Address - Country:US
Practice Address - Phone:614-251-0222
Practice Address - Fax:614-251-0258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1946111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty