Provider Demographics
NPI:1427083260
Name:BROUSSARD, ANDRE (DC)
Entity type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:
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 1:6701 ABERDEEN AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-1519
Mailing Address - Country:US
Mailing Address - Phone:806-796-0098
Mailing Address - Fax:806-796-0976
Practice Address - Street 1:6701 ABERDEEN AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-1519
Practice Address - Country:US
Practice Address - Phone:806-796-0098
Practice Address - Fax:806-796-0976
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4880111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT81922Medicare UPIN