Provider Demographics
NPI:1427143981
Name:BOUDREAU, EDWARD JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JOHN
Last Name:BOUDREAU
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 W WENDOVER AVE STE A
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-1585
Mailing Address - Country:US
Mailing Address - Phone:386-341-2558
Mailing Address - Fax:
Practice Address - Street 1:3410 W WENDOVER AVE STE A
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-1585
Practice Address - Country:US
Practice Address - Phone:386-341-2558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3503111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor