Provider Demographics
NPI:1558398289
Name:RICHARDS, CAROL (ATC)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11149 MONARCH LANDING DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-1529
Mailing Address - Country:US
Mailing Address - Phone:904-710-2266
Mailing Address - Fax:
Practice Address - Street 1:12276 SAN JOSE BLVD
Practice Address - Street 2:SUITE 717
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8628
Practice Address - Country:US
Practice Address - Phone:904-288-9604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL1679174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL1679OtherLICENSE NO.