Provider Demographics
NPI:1699029876
Name:BERTHIAUME CHIROPRACTIC PA
Entity Type:Organization
Organization Name:BERTHIAUME CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHRD
Authorized Official - Middle Name:G
Authorized Official - Last Name:BERTHIAUME
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:321-504-3737
Mailing Address - Street 1:1197 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2713
Mailing Address - Country:US
Mailing Address - Phone:321-504-3737
Mailing Address - Fax:321-504-4454
Practice Address - Street 1:1197 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2713
Practice Address - Country:US
Practice Address - Phone:321-504-3737
Practice Address - Fax:321-504-4454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-09
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6888111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381141700Medicaid
FL381141700Medicaid