Provider Demographics
NPI:1235143488
Name:THERIAULT, JAMES VINCENT (DC)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:VINCENT
Last Name:THERIAULT
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 1:1846 TAMIAMI TRL S
Mailing Address - Street 2:UNIT 1
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-3135
Mailing Address - Country:US
Mailing Address - Phone:941-497-7005
Mailing Address - Fax:941-493-6905
Practice Address - Street 1:1846 TAMIAMI TRL S
Practice Address - Street 2:UNIT 101
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-3135
Practice Address - Country:US
Practice Address - Phone:941-497-7005
Practice Address - Fax:941-493-6905
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0003467111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL88556Medicare ID - Type Unspecified