Provider Demographics
NPI:1689601569
Name:BOOTHE, SAMUEL KENNETH (DC)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:KENNETH
Last Name:BOOTHE
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 1:340 N MAIN ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-3360
Mailing Address - Country:US
Mailing Address - Phone:276-783-7005
Mailing Address - Fax:276-783-8080
Practice Address - Street 1:340 N MAIN ST
Practice Address - Street 2:STE 108
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354
Practice Address - Country:US
Practice Address - Phone:276-783-7005
Practice Address - Fax:276-783-8080
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104555931111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
434850OtherANTHEM
VA350001188Medicare PIN
434850OtherANTHEM