Healthcare Provider Details

I. General information

NPI: 1720596968
Provider Name (Legal Business Name): RISHI TUSHAR BODALIA DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6030 WHISPERING TREES LN
PORT ORANGE FL
32128-7352
US

IV. Provider business mailing address

6030 WHISPERING TREES LN
PORT ORANGE FL
32128-7352
US

V. Phone/Fax

Practice location:
  • Phone: 716-207-2800
  • Fax:
Mailing address:
  • Phone: 716-207-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License NumberCH13948
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License Number038013247
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License NumberX013037
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License Number2301401186
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: