Provider Demographics
NPI:1043227994
Name:BOURASSA, DANIEL J (DC PHD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:J
Last Name:BOURASSA
Suffix:
Gender:M
Credentials:DC PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E DE SOTO ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-3439
Mailing Address - Country:US
Mailing Address - Phone:850-250-2730
Mailing Address - Fax:
Practice Address - Street 1:103 NIGHTINGALE LN
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4300
Practice Address - Country:US
Practice Address - Phone:850-250-2730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 6116111N00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCH0006116OtherLICENSE FOR FLORIDA
AL59-3142428OtherTAX IDENTIFICATION NUMBER
AL1264OtherLICENSE FOR ALABAMA
FLCH0006116OtherLICENSE FOR FLORIDA
AL51092789BOUOtherALABAMA PROVIDER NUMBER
FL3801055-00Medicare ID - Type UnspecifiedFLORIDA MEDICAID NUMBER