Provider Demographics
NPI:1598029555
Name:RAY, RICHARD DEAN (LMT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DEAN
Last Name:RAY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16514 NW 78TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32615-7607
Mailing Address - Country:US
Mailing Address - Phone:352-317-4348
Mailing Address - Fax:
Practice Address - Street 1:12830 SW 1ST LN
Practice Address - Street 2:SUITE 100
Practice Address - City:NEWBERRY
Practice Address - State:FL
Practice Address - Zip Code:32669-3260
Practice Address - Country:US
Practice Address - Phone:352-317-4348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 57948225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist