Provider Demographics
NPI:1659389609
Name:BOUCHEREAU, RAYMOND JR
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:
Last Name:BOUCHEREAU
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6456 YORK BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-3642
Mailing Address - Country:US
Mailing Address - Phone:132-325-4433
Mailing Address - Fax:
Practice Address - Street 1:6456 YORK BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-3642
Practice Address - Country:US
Practice Address - Phone:132-325-4433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 13282111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor