Provider Demographics
NPI:1801863402
Name:VILLE, SUSAN V (DC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:V
Last Name:VILLE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:VAN VLIET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:2222 S HARBOR CITY BLVD STE 610
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-5591
Mailing Address - Country:US
Mailing Address - Phone:321-723-7716
Mailing Address - Fax:321-723-0604
Practice Address - Street 1:2222 S HARBOR CITY BLVD
Practice Address - Street 2:SUITE 530
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-5594
Practice Address - Country:US
Practice Address - Phone:321-723-7716
Practice Address - Fax:321-723-0604
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5937111NX0800X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL382129300Medicaid
FL382129300Medicaid
FL22515XMedicare PIN