Healthcare Provider Details

I. General information

NPI: 1760726301
Provider Name (Legal Business Name): BROTHERTON FAMILY AND SPORTS CHIROPRACTIC P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2012
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 MAIN ST
LAKE VIEW IA
51450-7710
US

IV. Provider business mailing address

406 MAIN ST
LAKE VIEW IA
51450-7710
US

V. Phone/Fax

Practice location:
  • Phone: 712-665-4099
  • Fax:
Mailing address:
  • Phone: 712-665-4099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number007583
License Number StateIA

VIII. Authorized Official

Name: AMANDA BENGFORD
Title or Position: D.C.
Credential:
Phone: 712-665-4099