Healthcare Provider Details

I. General information

NPI: 1730648411
Provider Name (Legal Business Name): MONTE BROUSSARD DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2019
Last Update Date: 03/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2707 N BROADWAY ST STE A
PITTSBURG KS
66762-2624
US

IV. Provider business mailing address

2707 N BROADWAY ST STE A
PITTSBURG KS
66762-2624
US

V. Phone/Fax

Practice location:
  • Phone: 620-308-5374
  • Fax:
Mailing address:
  • Phone: 620-308-5374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0105968
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: