Provider Demographics
NPI:1508910506
Name:D'AGOSTINO, DERIC (DC)
Entity Type:Individual
Prefix:DR
First Name:DERIC
Middle Name:
Last Name:D'AGOSTINO
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 1:5913 NORMANDY BLVD STE 13
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-6269
Mailing Address - Country:US
Mailing Address - Phone:904-786-2781
Mailing Address - Fax:904-786-9954
Practice Address - Street 1:5913 NORMANDY BLVD STE 13
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-6269
Practice Address - Country:US
Practice Address - Phone:904-786-2781
Practice Address - Fax:904-786-9954
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8829111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor