Provider Demographics
NPI:1063030062
Name:RICHARDSON PROSTHETICS & ORTHOTICS LLC
Entity Type:Organization
Organization Name:RICHARDSON PROSTHETICS & ORTHOTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONDELL
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:CO, BOCP
Authorized Official - Phone:704-510-2204
Mailing Address - Street 1:3210 PROSPERITY CHURCH RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-8194
Mailing Address - Country:US
Mailing Address - Phone:704-510-2204
Mailing Address - Fax:
Practice Address - Street 1:3210 PROSPERITY CHURCH RD STE 101
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-8194
Practice Address - Country:US
Practice Address - Phone:704-510-2204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-07
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC157863421Medicaid