=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255545885
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRODHEAD CHIROPRACTIC CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2007
-----------------------------------------------------
Last Update Date | 08/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 807 16TH ST
-----------------------------------------------------
City | BRODHEAD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53520-1744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-897-3080
-----------------------------------------------------
Fax | 608-897-4353
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 807 16TH STREET
-----------------------------------------------------
City | BRODHEAD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-897-3080
-----------------------------------------------------
Fax | 608-897-4353
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC DIRECTOR
-----------------------------------------------------
Name | DR. DAWN ANN SMITH
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 608-897-3080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 06573
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3969
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------