Provider Demographics
NPI:1255665089
Name:RICHARDS, CAMERON (LMT)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11064 QUEENS BLVD
Mailing Address - Street 2:#505
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-6347
Mailing Address - Country:US
Mailing Address - Phone:718-249-6100
Mailing Address - Fax:888-205-2971
Practice Address - Street 1:16027 121ST AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-2408
Practice Address - Country:US
Practice Address - Phone:718-249-6100
Practice Address - Fax:888-205-2971
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-25
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27-023147225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist