=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275755092
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROADWAY CHIROPRACTIC CLINIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 10/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 N AVENUE SUITE 4
-----------------------------------------------------
City | COUNCIL BLUFFS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-322-8504
-----------------------------------------------------
Fax | 402-614-5823
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 N AVENUE SUITE 4
-----------------------------------------------------
City | COUNCIL BLUFFS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-322-8504
-----------------------------------------------------
Fax | 402-614-5823
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DEANNA JEAN ROGGE
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 712-322-8504
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 04972
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------