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General NPI Number Information
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NPI Number | 1003905084
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Entity Type | Organization
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Legal Business Name | ETHEREDGE CHIROPRACTIC PA
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Dates
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Enumeration Date | 10/11/2006
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Last Update Date | 08/21/2007
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Provider Practice Location Address
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Address Line | 3261 US HWY 27/441
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City | FRUITLAND PARK
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State | FL
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Zip | 34731
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Country | US
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Telephone | 352-365-1191
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Fax | 352-365-0330
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Provider Business Mailing Address
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Address Line | 3261 US HWY 27/441
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City | FRUITLAND PARK
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State | FL
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Zip | 34731
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Country | US
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Telephone | 352-365-1191
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Fax | 352-365-0330
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Authorized Official
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Title or Position | OWNER/CHIRPRACTOR
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Name | DR. RICHARD KIM ETHEREDGE
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Credential | DC
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Telephone | 352-365-1191
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NX0800X
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Taxonomy Name | Orthopedic Chiropractor
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License Number |
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License Number State |
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