=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881743458
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDRENS CHIROPRACTIC CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2007
-----------------------------------------------------
Last Update Date | 11/21/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1123 N EVERGREEN RD
-----------------------------------------------------
City | SPOKANE VALLEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99216-1138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-891-5567
-----------------------------------------------------
Fax | 509-891-1506
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1123 N EVERGREEN RD
-----------------------------------------------------
City | SPOKANE VALLEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99216-1138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-891-5567
-----------------------------------------------------
Fax | 509-891-1506
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TRAVIS D BROUGHTON
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 509-891-5567
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH00003335
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------