Provider Demographics
NPI:1033589429
Name:COLONEL, RICHARD LEE
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEE
Last Name:COLONEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 571
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:FL
Mailing Address - Zip Code:32640-0571
Mailing Address - Country:US
Mailing Address - Phone:352-642-5085
Mailing Address - Fax:877-481-8035
Practice Address - Street 1:143 MELROSE LANDING DR
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:FL
Practice Address - Zip Code:32640-4417
Practice Address - Country:US
Practice Address - Phone:352-642-5085
Practice Address - Fax:877-481-8035
Is Sole Proprietor?:No
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLC454752523700172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver