Provider Demographics
NPI:1497848428
Name:BOUCHARD, ROBERT RALPH JR (DC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:RALPH
Last Name:BOUCHARD
Suffix:JR
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 1:1104 GAULT AVE S # A
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35967-4920
Mailing Address - Country:US
Mailing Address - Phone:256-844-8215
Mailing Address - Fax:256-844-8210
Practice Address - Street 1:1104 GAULT AVE S # A
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35967-4920
Practice Address - Country:US
Practice Address - Phone:256-844-8215
Practice Address - Fax:256-844-8210
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1987111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL5150338BOUOtherBLUE CROSS
AL631263185OtherTAX ID
ALU84425Medicare UPIN
AL5150338BOUOtherBLUE CROSS