Provider Demographics
NPI:1821122904
Name:BROADMOOR CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:BROADMOOR CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-868-5009
Mailing Address - Street 1:5805 E KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4303
Mailing Address - Country:US
Mailing Address - Phone:318-868-5009
Mailing Address - Fax:318-865-4451
Practice Address - Street 1:5805 E KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4303
Practice Address - Country:US
Practice Address - Phone:318-868-5009
Practice Address - Fax:318-865-4451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA=========OtherTAX ID NUMBER