Provider Demographics
NPI:1669668828
Name:KIDWELL, RICHARD M (PT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:M
Last Name:KIDWELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 TIMBERLAKE MANOR PKWY
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5584
Mailing Address - Country:US
Mailing Address - Phone:636-778-0584
Mailing Address - Fax:
Practice Address - Street 1:1555 TIMBERLAKE MANOR PKWY
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5584
Practice Address - Country:US
Practice Address - Phone:636-778-0584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00714225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist