Healthcare Provider Details

I. General information

NPI: 1184694788
Provider Name (Legal Business Name): GENE LOUIS BOUCHER DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 04/03/2020
Certification Date: 04/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 MILL ST
FAIRFIELD NJ
07004-3824
US

IV. Provider business mailing address

26 MILL ST
FAIRFIELD NJ
07004-3824
US

V. Phone/Fax

Practice location:
  • Phone: 736-505-2259
  • Fax:
Mailing address:
  • Phone: 973-650-5225
  • Fax: 973-345-4119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberMC005511
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: