Healthcare Provider Details

I. General information

NPI: 1003905084
Provider Name (Legal Business Name): ETHEREDGE CHIROPRACTIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3261 US HWY 27/441
FRUITLAND PARK FL
34731
US

IV. Provider business mailing address

3261 US HWY 27/441
FRUITLAND PARK FL
34731
US

V. Phone/Fax

Practice location:
  • Phone: 352-365-1191
  • Fax: 352-365-0330
Mailing address:
  • Phone: 352-365-1191
  • Fax: 352-365-0330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD KIM ETHEREDGE
Title or Position: OWNER/CHIRPRACTOR
Credential: DC
Phone: 352-365-1191