Provider Demographics
NPI:1538436423
Name:TRAVIS D. BROUGHTON
Entity type:Organization
Organization Name:TRAVIS D. BROUGHTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:DERRILL
Authorized Official - Last Name:BROUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:509-220-0872
Mailing Address - Street 1:223 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2651
Mailing Address - Country:US
Mailing Address - Phone:208-215-3261
Mailing Address - Fax:208-966-4284
Practice Address - Street 1:223 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2651
Practice Address - Country:US
Practice Address - Phone:208-215-3261
Practice Address - Fax:208-966-4284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-21
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty