Healthcare Provider Details

I. General information

NPI: 1689732778
Provider Name (Legal Business Name): GERALD C BOOTH DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 09/30/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55741 NATIONAL RD
BRIDGEPORT OH
43912-1528
US

IV. Provider business mailing address

55741 NATIONAL RD
BRIDGEPORT OH
43912-1528
US

V. Phone/Fax

Practice location:
  • Phone: 740-633-9922
  • Fax: 740-633-9924
Mailing address:
  • Phone: 740-633-9922
  • Fax: 740-633-9924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2480
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: