1073546727 NPI number — RICHARD G BERTHIAUME B.S.,D.C.

Table of content: RICHARD G BERTHIAUME B.S.,D.C. (NPI 1073546727)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073546727 NPI number — RICHARD G BERTHIAUME B.S.,D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERTHIAUME
Provider First Name:
RICHARD
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
B.S.,D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073546727
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
272 CHURCHILL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32779-4619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-720-8185
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1197 US HIGHWAY 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKLEDGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32955-2713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-504-3737
Provider Business Practice Location Address Fax Number:
321-504-4454
Provider Enumeration Date:
07/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH6888 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 381141700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com