Provider Demographics
NPI:1003905084
Name:ETHEREDGE CHIROPRACTIC PA
Entity Type:Organization
Organization Name:ETHEREDGE CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIRPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:ETHEREDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:352-365-1191
Mailing Address - Street 1:3261 US HWY 27/441
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34731
Mailing Address - Country:US
Mailing Address - Phone:352-365-1191
Mailing Address - Fax:352-365-0330
Practice Address - Street 1:3261 US HWY 27/441
Practice Address - Street 2:
Practice Address - City:FRUITLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:34731
Practice Address - Country:US
Practice Address - Phone:352-365-1191
Practice Address - Fax:352-365-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty