Provider Demographics
NPI:1073546727
Name:BERTHIAUME, RICHARD G (BS,DC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:G
Last Name:BERTHIAUME
Suffix:
Gender:M
Credentials:BS,DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 CHURCHILL DR
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-4619
Mailing Address - Country:US
Mailing Address - Phone:321-720-8185
Mailing Address - Fax:
Practice Address - Street 1:1197 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2713
Practice Address - Country:US
Practice Address - Phone:321-504-3737
Practice Address - Fax:321-504-4454
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6888111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381141700Medicaid