Provider Demographics
NPI:1104523679
Name:THERIAULT CHIROPRACTIC
Entity type:Organization
Organization Name:THERIAULT CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:THERIAULT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:941-497-7005
Mailing Address - Street 1:1846 S TAMIAMI TRL STE 1
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-3135
Mailing Address - Country:US
Mailing Address - Phone:941-497-7005
Mailing Address - Fax:341-493-6905
Practice Address - Street 1:1846 S TAMIAMI TRL STE 1
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-3135
Practice Address - Country:US
Practice Address - Phone:941-497-7005
Practice Address - Fax:341-493-6905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3467OtherDC