Healthcare Provider Details

I. General information

NPI: 1750990024
Provider Name (Legal Business Name): BROAD AVE CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

669 BROAD AVE STE 204
RIDGEFIELD NJ
07657-1631
US

IV. Provider business mailing address

669 BROAD AVE STE 204
RIDGEFIELD NJ
07657-1631
US

V. Phone/Fax

Practice location:
  • Phone: 201-917-3300
  • Fax: 201-917-3302
Mailing address:
  • Phone: 201-917-3300
  • Fax: 201-917-3302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: HYUNIK HWANGBO
Title or Position: PRESIDENT
Credential: DC
Phone: 914-450-8881