Provider Demographics
NPI:1376893180
Name:BLEDSOE, RICHARD CARROLL (PT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:CARROLL
Last Name:BLEDSOE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:RICHARD
Other - Middle Name:CARROLL
Other - Last Name:BLEDSOE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:2501 SOUTH VOLUSIA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763
Mailing Address - Country:US
Mailing Address - Phone:386-774-6333
Mailing Address - Fax:888-465-1815
Practice Address - Street 1:2501 SOUTH VOLUSIA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763
Practice Address - Country:US
Practice Address - Phone:386-774-6333
Practice Address - Fax:888-465-1815
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT26750225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist