=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902948722
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID JOSEPH DERAIMO DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2007
-----------------------------------------------------
Last Update Date | 05/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 612 MAIN ST
-----------------------------------------------------
City | CHAPMANVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-855-4529
-----------------------------------------------------
Fax | 304-855-5112
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4357
-----------------------------------------------------
City | CHAPMANVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25508-4357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-855-4529
-----------------------------------------------------
Fax | 304-855-5112
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 861
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------