Provider Demographics
NPI:1982959011
Name:BROADWAY ERGONOMICS, LLC
Entity Type:Organization
Organization Name:BROADWAY ERGONOMICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRET
Authorized Official - Middle Name:SHERIDAN
Authorized Official - Last Name:DERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:573-808-2392
Mailing Address - Street 1:111 E BROADWAY
Mailing Address - Street 2:SUITE 340
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-4208
Mailing Address - Country:US
Mailing Address - Phone:573-808-2392
Mailing Address - Fax:888-738-3034
Practice Address - Street 1:111 E BROADWAY
Practice Address - Street 2:SUITE 340
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-4208
Practice Address - Country:US
Practice Address - Phone:573-808-2392
Practice Address - Fax:888-738-3034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-15
Last Update Date:2012-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO021482251E1200X
MO20100281792251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomicsGroup - Multi-Specialty