MEDICARE: DR. CARL EDWARD BROOM D.C.

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	111N00000X	Chiropractor	9253	TX

General Provider Information

NPI Number	:	1639247067
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARL EDWARD BROOM D.C.

Provider Business Mailing Address
First Line	:	14873 GRANADA DR
Second Line	:	UNIT 11
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78418-7902
Country	:	US
Telephone Number	:	361-949-7687
Fax Number	:

Provider Business Practice Location Address
First Line	:	6170 IH 10 E
Second Line	:	BUILDING 2
City	:	SAN ANTONIO
State	:	TX
Zip	:	78219-4507
Country	:	US
Telephone Number	:	210-661-4800
Fax Number	:	210-661-4808

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	07/08/2007

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