Provider Demographics
NPI:1093725574
Name:MERRILL, ANDRE J (DC)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:J
Last Name:MERRILL
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 1:152 N HARBOR CITY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-6794
Mailing Address - Country:US
Mailing Address - Phone:321-242-2676
Mailing Address - Fax:321-242-2675
Practice Address - Street 1:152 N HARBOR CITY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-6794
Practice Address - Country:US
Practice Address - Phone:321-242-2676
Practice Address - Fax:321-242-2675
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH4982111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
70678Medicare PIN
FLT85481Medicare UPIN