Healthcare Provider Details

I. General information

NPI: 1669590055
Provider Name (Legal Business Name): LAUREL EVANS BROADHURST M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 TABERNACLE RD JFK-ADATC
BLACK MOUNTAIN NC
28711-2526
US

IV. Provider business mailing address

1000S STERLING ST
MORGANTON NC
28655-3938
US

V. Phone/Fax

Practice location:
  • Phone: 828-669-3455
  • Fax:
Mailing address:
  • Phone: 828-433-2566
  • Fax: 828-433-2242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number009501185
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: