Provider Demographics
NPI:1497100119
Name:BROADSTONE, RAINA LEE (DC)
Entity type:Individual
Prefix:DR
First Name:RAINA
Middle Name:LEE
Last Name:BROADSTONE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:RAINA
Other - Middle Name:LEE
Other - Last Name:DOBBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:215 W CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:GLADWIN
Mailing Address - State:MI
Mailing Address - Zip Code:48624-2019
Mailing Address - Country:US
Mailing Address - Phone:989-282-1881
Mailing Address - Fax:
Practice Address - Street 1:215 W CEDAR AVE
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-2019
Practice Address - Country:US
Practice Address - Phone:989-282-1881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-02
Last Update Date:2024-07-30
Deactivation Date:2022-07-12
Deactivation Code:
Reactivation Date:2023-05-09
Provider Licenses
StateLicense IDTaxonomies
MI2301010370111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor