=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932377934
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROADSTONE CHIROPRACTIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2008
-----------------------------------------------------
Last Update Date | 02/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2690 E. BIDWELL ST. SUITE 400
-----------------------------------------------------
City | FOLSOM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-983-7771
-----------------------------------------------------
Fax | 916-983-7996
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2690 E BIDWELL ST SUITE 400
-----------------------------------------------------
City | FOLSOM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95630-6430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-983-7771
-----------------------------------------------------
Fax | 916-983-7996
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. CASEY LEIGH WILSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-983-7771
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | DC28846
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------