Provider Demographics
NPI:1881743458
Name:CHILDRENS CHIROPRACTIC CENTER INC
Entity type:Organization
Organization Name:CHILDRENS CHIROPRACTIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:D
Authorized Official - Last Name:BROUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:509-891-5567
Mailing Address - Street 1:1123 N EVERGREEN RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1138
Mailing Address - Country:US
Mailing Address - Phone:509-891-5567
Mailing Address - Fax:509-891-1506
Practice Address - Street 1:1123 N EVERGREEN RD
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1138
Practice Address - Country:US
Practice Address - Phone:509-891-5567
Practice Address - Fax:509-891-1506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003335111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU63679Medicare UPIN
WAG 8863247Medicare PIN
WAG 8862706Medicare PIN