Provider Demographics
NPI:1255545885
Name:BRODHEAD CHIROPRACTIC CENTER LLC
Entity type:Organization
Organization Name:BRODHEAD CHIROPRACTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-897-3080
Mailing Address - Street 1:807 16TH STREET
Mailing Address - Street 2:
Mailing Address - City:BRODHEAD
Mailing Address - State:WI
Mailing Address - Zip Code:53520
Mailing Address - Country:US
Mailing Address - Phone:608-897-3080
Mailing Address - Fax:608-897-4353
Practice Address - Street 1:807 16TH ST
Practice Address - Street 2:
Practice Address - City:BRODHEAD
Practice Address - State:WI
Practice Address - Zip Code:53520-1744
Practice Address - Country:US
Practice Address - Phone:608-897-3080
Practice Address - Fax:608-897-4353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06573111N00000X
WI3969111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38954500Medicaid
U97613Medicare UPIN
WI38954500Medicaid