Provider Demographics
NPI:1740373216
Name:MOUTSOPOULOS, CATHERINE ELAINE (DC)
Entity type:Individual
Prefix:DR
First Name:CATHERINE
Middle Name:ELAINE
Last Name:MOUTSOPOULOS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:940 NORTH HALIFAX AVENUE
Mailing Address - Street 2:CLINIC
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-3733
Mailing Address - Country:US
Mailing Address - Phone:386-255-4338
Mailing Address - Fax:386-248-1104
Practice Address - Street 1:940 NORTH HALIFAX AVENUE
Practice Address - Street 2:CLINIC
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32118-3733
Practice Address - Country:US
Practice Address - Phone:386-255-4338
Practice Address - Fax:386-248-1104
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL7702111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381589700Medicaid
FL381589700Medicaid
U90732Medicare UPIN
FL043617670OtherTAX ID NUMBER