Provider Demographics
NPI:1548387301
Name:BROADWAY CHIROPRACTIC INC
Entity Type:Organization
Organization Name:BROADWAY CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:REBARCAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-784-6682
Mailing Address - Street 1:5439 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1703
Mailing Address - Country:US
Mailing Address - Phone:773-784-6682
Mailing Address - Fax:773-784-5735
Practice Address - Street 1:5439 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1703
Practice Address - Country:US
Practice Address - Phone:773-784-6682
Practice Address - Fax:773-784-5735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38010607111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1003902560OtherNPI