Provider Demographics
NPI:1487794541
Name:BROADWAY CHIROPRACTIC CENTER PROFESSIONAL ASSOCIATION
Entity type:Organization
Organization Name:BROADWAY CHIROPRACTIC CENTER PROFESSIONAL ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:RAE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-345-3630
Mailing Address - Street 1:1149 W BOISE AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3503
Mailing Address - Country:US
Mailing Address - Phone:208-345-3630
Mailing Address - Fax:208-345-3640
Practice Address - Street 1:1149 W BOISE AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3503
Practice Address - Country:US
Practice Address - Phone:208-345-3630
Practice Address - Fax:208-345-3640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDC373111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC9511OtherBLUE CROSS
ID000010145978OtherBLUE SHIELD
IDC9511OtherBLUE CROSS
IDT44447Medicare UPIN