Provider Demographics
NPI:1932377934
Name:BROADSTONE CHIROPRACTIC INC
Entity type:Organization
Organization Name:BROADSTONE CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-983-7771
Mailing Address - Street 1:2690 E BIDWELL ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-6430
Mailing Address - Country:US
Mailing Address - Phone:916-983-7771
Mailing Address - Fax:916-983-7996
Practice Address - Street 1:2690 E. BIDWELL ST.
Practice Address - Street 2:SUITE 400
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630
Practice Address - Country:US
Practice Address - Phone:916-983-7771
Practice Address - Fax:916-983-7996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28846261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0288461Medicare PIN