Provider Demographics
NPI:1780735894
Name:DR. DAVID L. BROUILLETTE, D.C., S.C.
Entity type:Organization
Organization Name:DR. DAVID L. BROUILLETTE, D.C., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROUILLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-692-6747
Mailing Address - Street 1:511 FREDONIA AVE
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:WI
Mailing Address - Zip Code:53021-9406
Mailing Address - Country:US
Mailing Address - Phone:262-692-6747
Mailing Address - Fax:262-692-6547
Practice Address - Street 1:511 FREDONIA AVE
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:WI
Practice Address - Zip Code:53021-9406
Practice Address - Country:US
Practice Address - Phone:262-692-6747
Practice Address - Fax:262-692-6547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2907111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1245234772OtherNPI # TYPE 1
WI1245234772OtherNPI # TYPE 1