=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952176182
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROOM CHIROPRACTIC AND SPORTS THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2023
-----------------------------------------------------
Last Update Date | 11/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 BECKY LN
-----------------------------------------------------
City | GREENBRIER
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72058-9200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-314-4484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32 SPRING RIDGE LN
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72032-5036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-314-4484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DC
-----------------------------------------------------
Name | CHRISTOPHER LUKE BROOM
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 501-314-4484
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------