Provider Demographics
NPI:1467008565
Name:RICHARDSON, GREGORY MANCE (AT;C LLC)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:MANCE
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:AT;C LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5232 NE 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-5626
Mailing Address - Country:US
Mailing Address - Phone:954-732-7350
Mailing Address - Fax:
Practice Address - Street 1:5232 NE 18TH AVE
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-5626
Practice Address - Country:US
Practice Address - Phone:954-732-7350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL5702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer