Provider Demographics
NPI:1851916233
Name:BROADHEAD, NICHOLAS (DC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:BROADHEAD
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 1:2780 W FOX HUNTERS LOOP
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-6002
Mailing Address - Country:US
Mailing Address - Phone:801-882-3524
Mailing Address - Fax:
Practice Address - Street 1:3450 N TRIUMPH BLVD STE 102
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-6132
Practice Address - Country:US
Practice Address - Phone:801-316-8249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11105158-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty