MEDICARE: DR. JENNIFER OTYLIA BROAD D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	DC 657	HI

General Provider Information

NPI Number	:	1194878207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER OTYLIA BROAD D.C.

Provider Business Mailing Address
First Line	:	91-1072 OPAEHUNA ST
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-3565
Country	:	US
Telephone Number	:	808-676-6855
Fax Number	:

Provider Business Practice Location Address
First Line	:	803 KAMEHAMEHA HWY STE 309
Second Line	:
City	:	PEARL CITY
State	:	HI
Zip	:	96782-2638
Country	:	US
Telephone Number	:	808-456-5553
Fax Number	:	808-455-6520

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	07/08/2007

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