Provider Demographics
NPI:1174292064
Name:RICH, ANTHONY RAYMOND JR
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:RAYMOND
Last Name:RICH
Suffix:JR
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:ANTHONY
Other - Middle Name:RAYMOND
Other - Last Name:RICH
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:DPT
Mailing Address - Street 1:2520 E WILCOX DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2843
Mailing Address - Country:US
Mailing Address - Phone:815-326-2196
Mailing Address - Fax:
Practice Address - Street 1:2520 E WILCOX DR
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2843
Practice Address - Country:US
Practice Address - Phone:815-326-2196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.026013225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070.026013OtherILLINOIS LICENSE NUMBER