MEDICARE: TERESA ANN BOUCHARD D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	X002932-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6687175	OTHER	NY	CIGNA
2	0878669	OTHER	NY	AETNA
3	0079064	OTHER	NY	GHI
4	X4495	OTHER	NY	BLUECROSS/BLUESHIELD

General Provider Information

NPI Number	:	1487682548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA ANN BOUCHARD D.C.

Provider Business Mailing Address
First Line	:	371 NASSAU BLVD
Second Line	:
City	:	GARDEN CITY PARK
State	:	NY
Zip	:	11040-5254
Country	:	US
Telephone Number	:	516-248-3647
Fax Number	:	516-414-8519

Provider Business Practice Location Address
First Line	:	371 NASSAU BLVD
Second Line	:
City	:	GARDEN CITY PARK
State	:	NY
Zip	:	11040-5254
Country	:	US
Telephone Number	:	516-248-3647
Fax Number	:	516-414-8519

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	07/08/2007

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