MEDICARE: BROADWAY SOUTH CHIROPRACTIC CLINIC PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NI0900X	Internist Chiropractor	968	CO

General Provider Information

NPI Number	:	1407197742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROADWAY SOUTH CHIROPRACTIC CLINIC PC

Provider Business Mailing Address
First Line	:	3601 S BROADWAY
Second Line	:
City	:	ENGLEWOOD
State	:	CO
Zip	:	80113-3610
Country	:	US
Telephone Number	:	303-761-8521
Fax Number	:

Provider Business Practice Location Address
First Line	:	3601 S BROADWAY
Second Line	:
City	:	ENGLEWOOD
State	:	CO
Zip	:	80113-3610
Country	:	US
Telephone Number	:	303-761-8521
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BRAIN K WILSON
Credential	:	DC
Telephone Number	:	303-761-8521

Provider Enumeration Date	:	03/12/2013
Last Update Date	:	03/12/2013

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