Healthcare Provider Details

I. General information

NPI: 1407941438
Provider Name (Legal Business Name): MICHAEL RONALD BOUCHER D. C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2834 ACUSHNET AVE
NEW BEDFORD MA
02745-3412
US

IV. Provider business mailing address

12 BEECHWOOD DR
ACUSHNET MA
02743-1879
US

V. Phone/Fax

Practice location:
  • Phone: 508-998-3001
  • Fax: 508-998-1461
Mailing address:
  • Phone: 508-998-3816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH 1837
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: