Provider Demographics
NPI:1851586606
Name:BROAD RIPPLE AVE CHIROPRACTIC, P.C.
Entity Type:Organization
Organization Name:BROAD RIPPLE AVE CHIROPRACTIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:B
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:317-255-4222
Mailing Address - Street 1:PO BOX 20884
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-0884
Mailing Address - Country:US
Mailing Address - Phone:317-255-4222
Mailing Address - Fax:317-251-3801
Practice Address - Street 1:4760 E 62ND ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-5234
Practice Address - Country:US
Practice Address - Phone:317-255-4222
Practice Address - Fax:317-251-3801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ08001498111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100441610Medicaid
IN000000222754OtherBLUE CROSS/BLUE SHIELD
IN000000222754OtherBLUE CROSS/BLUE SHIELD
INU45559Medicare UPIN