Provider Demographics
NPI:1376729376
Name:PROVENCHER, STEPHANE (DC)
Entity Type:Individual
Prefix:
First Name:STEPHANE
Middle Name:
Last Name:PROVENCHER
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 1:8006 CRESCENT PARK DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3444
Mailing Address - Country:US
Mailing Address - Phone:571-248-0695
Mailing Address - Fax:571-248-0964
Practice Address - Street 1:8006 CRESCENT PARK DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155
Practice Address - Country:US
Practice Address - Phone:571-248-0695
Practice Address - Fax:571-248-0964
Is Sole Proprietor?:No
Enumeration Date:2008-01-21
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008001511111N00000X
VA0104556839111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor