Provider Demographics
NPI:1699359802
Name:ROSS, RICHARD L IV (PTA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:L
Last Name:ROSS
Suffix:IV
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4344 LANGLEY AVE STE APT H145
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8554
Mailing Address - Country:US
Mailing Address - Phone:850-454-9607
Mailing Address - Fax:
Practice Address - Street 1:7830 PINE FOREST RD FL 32526
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32526-8404
Practice Address - Country:US
Practice Address - Phone:850-941-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9724225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant