Provider Demographics
NPI:1861761959
Name:BROADWAY PLAZA PAIN RELIEF CENTER
Entity type:Organization
Organization Name:BROADWAY PLAZA PAIN RELIEF CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:219-884-3250
Mailing Address - Street 1:5360 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-1555
Mailing Address - Country:US
Mailing Address - Phone:219-884-3250
Mailing Address - Fax:219-884-3828
Practice Address - Street 1:5360 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-1555
Practice Address - Country:US
Practice Address - Phone:219-884-3250
Practice Address - Fax:219-884-3828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001395A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100338150Medicaid
IN405430Medicare PIN