Provider Demographics
NPI:1639791684
Name:BROAD CHIROPRACTIC & WELLNESS PLLC
Entity Type:Organization
Organization Name:BROAD CHIROPRACTIC & WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:BROAD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-853-8517
Mailing Address - Street 1:2548 YELLOW STAR ST
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-1710
Mailing Address - Country:US
Mailing Address - Phone:630-853-8517
Mailing Address - Fax:
Practice Address - Street 1:2548 YELLOW STAR ST
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-1710
Practice Address - Country:US
Practice Address - Phone:630-853-8517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty