Provider Demographics
NPI:1578763421
Name:RICHARDSON, RONDELL L (CO, BOCP)
Entity Type:Individual
Prefix:
First Name:RONDELL
Middle Name:L
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:CO, BOCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 373
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28075-0373
Mailing Address - Country:US
Mailing Address - Phone:704-641-7221
Mailing Address - Fax:
Practice Address - Street 1:3210 PROSPERITY CHURCH RD STE 101
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-8194
Practice Address - Country:US
Practice Address - Phone:704-510-2204
Practice Address - Fax:704-510-2218
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2020-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO004511222Z00000X
C22362224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC260519964OtherEIN
NC6047340001Medicare NSC