Provider Demographics
NPI:1962582742
Name:BERRY, VIRGIL A JR (DC DABFP)
Entity type:Individual
Prefix:
First Name:VIRGIL
Middle Name:A
Last Name:BERRY
Suffix:JR
Gender:M
Credentials:DC DABFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E CALL ST
Mailing Address - Street 2:
Mailing Address - City:STARKE
Mailing Address - State:FL
Mailing Address - Zip Code:32091
Mailing Address - Country:US
Mailing Address - Phone:904-964-8018
Mailing Address - Fax:904-964-9131
Practice Address - Street 1:601 E CALL ST
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091
Practice Address - Country:US
Practice Address - Phone:904-964-8018
Practice Address - Fax:904-964-9131
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5217111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL050750400Medicaid
FL70979OtherBCBS
FL70979Medicare ID - Type Unspecified
FL70979OtherBCBS