Provider Demographics
NPI:1780861666
Name:EAGLE CREEK CHIROPRACTIC, PC
Entity Type:Organization
Organization Name:EAGLE CREEK CHIROPRACTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUCAS
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:BROMLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:317-299-3330
Mailing Address - Street 1:3820 N HIGH SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-2709
Mailing Address - Country:US
Mailing Address - Phone:317-299-3330
Mailing Address - Fax:317-299-0404
Practice Address - Street 1:3820 N HIGH SCHOOL RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2709
Practice Address - Country:US
Practice Address - Phone:317-299-3330
Practice Address - Fax:317-299-0404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001056111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100066750AMedicaid
INT81853Medicare PIN