Provider Demographics
NPI:1629012703
Name:BROAD, ERIC ALLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:ALLEN
Last Name:BROAD
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 1:43423 JOY RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2053
Mailing Address - Country:US
Mailing Address - Phone:734-354-9900
Mailing Address - Fax:734-354-8755
Practice Address - Street 1:43399 JOY RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48170
Practice Address - Country:US
Practice Address - Phone:734-354-9900
Practice Address - Fax:734-354-8755
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008122111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950H254060Medicare UPIN
MI0N13990Medicare ID - Type Unspecified