Provider Demographics
NPI:1679781561
Name:BROAD FAMILY CHIROPRACTIC
Entity type:Organization
Organization Name:BROAD FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BROAD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:734-354-9900
Mailing Address - Street 1:43423 JOY RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2053
Mailing Address - Country:US
Mailing Address - Phone:734-354-9900
Mailing Address - Fax:734-354-8755
Practice Address - Street 1:43399 JOY RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2076
Practice Address - Country:US
Practice Address - Phone:734-354-9900
Practice Address - Fax:734-354-8755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008122111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H23484Medicare UPIN
MI0N39310Medicare PIN