Provider Demographics
NPI:1780795294
Name:ETHEREDGE, RICHARD KIM (DC)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:KIM
Last Name:ETHEREDGE
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 1:3261 US HIGHWAY 27/441
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34731-4497
Mailing Address - Country:US
Mailing Address - Phone:352-365-1191
Mailing Address - Fax:352-365-0330
Practice Address - Street 1:3261 US HIGHWAY 441/27
Practice Address - Street 2:
Practice Address - City:FRUITLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:34731-4497
Practice Address - Country:US
Practice Address - Phone:352-365-1191
Practice Address - Fax:352-365-0330
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5758111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22261OtherBC
FL380121700Medicaid
T54846Medicare UPIN
K2507Medicare ID - Type Unspecified