Provider Demographics
NPI:1124088414
Name:BROUSSARD, JAMES COTY (DC)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:COTY
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6755 PHELAN BLVD
Mailing Address - Street 2:SUITE 18
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-6075
Mailing Address - Country:US
Mailing Address - Phone:409-866-7566
Mailing Address - Fax:
Practice Address - Street 1:6755 PHELAN BLVD
Practice Address - Street 2:SUITE18
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-6075
Practice Address - Country:US
Practice Address - Phone:409-866-7566
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9733111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX610653Medicare ID - Type Unspecified
TXV00072Medicare UPIN