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General NPI Number Information
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NPI Number | 1275952822
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Entity Type | Organization
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Legal Business Name | BROADWAY CHIROPRACTIC DIAGNOSTIC AND REHABILITATION P.C.
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Dates
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Enumeration Date | 04/10/2014
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Last Update Date | 04/10/2014
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Provider Practice Location Address
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Address Line | 333 BROADWAY STE 2
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City | AMITYVILLE
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State | NY
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Zip | 11701-2719
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Country | US
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Telephone | 631-789-1900
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Fax |
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Provider Business Mailing Address
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Address Line | 333 BROADWAY STE 2
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City | AMITYVILLE
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State | NY
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Zip | 11701-2719
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Country | US
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Telephone | 631-789-1900
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | MR. MICHAEL GRAMSE
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Credential | DC
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Telephone | 631-789-1900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | X007459
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License Number State | NY
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