=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841304482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4001 HOLLYWOOD BLVD
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33021-6792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-987-2528
-----------------------------------------------------
Fax | 954-987-2629
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4001 HOLLYWOOD BLVD
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33021-6792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-987-2528
-----------------------------------------------------
Fax | 954-987-2629
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. STEVE ATHAN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 954-987-2528
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH 9173
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------