Provider Demographics
NPI:1083770671
Name:BOUDREAU, JOSEPH TODD (DC)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:TODD
Last Name:BOUDREAU
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 US HIGHWAY 9
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LANOKA HARBOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08734-2818
Mailing Address - Country:US
Mailing Address - Phone:609-971-0101
Mailing Address - Fax:609-971-0109
Practice Address - Street 1:411 US HIGHWAY 9
Practice Address - Street 2:SUITE 1
Practice Address - City:LANOKA HARBOR
Practice Address - State:NJ
Practice Address - Zip Code:08734-2818
Practice Address - Country:US
Practice Address - Phone:609-971-0101
Practice Address - Fax:609-971-0109
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 7984111N00000X
NJ38MC00657100111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ111509WL9OtherRENERING PROVIDER NUMBER