Provider Demographics
NPI:1275610081
Name:COCKRELL, RICHARD QUINT (DC)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:QUINT
Last Name:COCKRELL
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 1:15324 MAIN ST E STE B
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-2698
Mailing Address - Country:US
Mailing Address - Phone:253-863-5323
Mailing Address - Fax:253-863-2034
Practice Address - Street 1:15324 MAIN ST E STE B
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:WA
Practice Address - Zip Code:98390-2698
Practice Address - Country:US
Practice Address - Phone:253-863-5323
Practice Address - Fax:253-863-2034
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601435589111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA601367608OtherUBI NUMBER
WA911580839OtherFED TAX ID NUMBER
WA911580839OtherFED TAX ID NUMBER
WAAB36129Medicare ID - Type UnspecifiedGROUP/CHC