Provider Demographics
NPI:1659794733
Name:RICHARDSON, ALYSSE CORAVON (DC)
Entity Type:Individual
Prefix:
First Name:ALYSSE
Middle Name:CORAVON
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 NW 119TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33168-2522
Mailing Address - Country:US
Mailing Address - Phone:305-688-0811
Mailing Address - Fax:
Practice Address - Street 1:671 NW 119TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33168-2522
Practice Address - Country:US
Practice Address - Phone:305-688-0811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 11040111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020665100Medicaid