Provider Demographics
NPI:1710652185
Name:GERVAIS, COLTON ROSS
Entity Type:Individual
Prefix:
First Name:COLTON
Middle Name:ROSS
Last Name:GERVAIS
Suffix:
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 1:309 TOLLHOUSE PL APT 104G
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-9777
Mailing Address - Country:US
Mailing Address - Phone:207-899-9417
Mailing Address - Fax:
Practice Address - Street 1:222 S DUPONT HWY
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-3797
Practice Address - Country:US
Practice Address - Phone:302-744-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEF1-0011057111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor