=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184648776
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROUSSARD FAMILY CHIROPRACTIC, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6755 PHELAN BLVD SUITE 18
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77706-6075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-866-7566
-----------------------------------------------------
Fax | 409-866-9566
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6755 PHELAN BLVD SUITE 18
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77706-6075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-866-7566
-----------------------------------------------------
Fax | 409-866-9566
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JAMES COTY BROUSSARD
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 409-866-7566
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 9733
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------