Provider Demographics
NPI:1225265572
Name:RERUCHA, JEROME JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:JOSEPH
Last Name:RERUCHA
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 1:2642 GADSEN WALK
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-4350
Mailing Address - Country:US
Mailing Address - Phone:678-350-5920
Mailing Address - Fax:
Practice Address - Street 1:2642 GADSEN WALK
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-4350
Practice Address - Country:US
Practice Address - Phone:678-350-5920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-14
Last Update Date:2009-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007549111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCHVHMedicare UPIN