Provider Demographics
NPI:1710204219
Name:RICHARDSON, MATTHEW DALE (DC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DALE
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 S CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-4103
Mailing Address - Country:US
Mailing Address - Phone:386-763-2718
Mailing Address - Fax:386-763-2719
Practice Address - Street 1:4705 S CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-4103
Practice Address - Country:US
Practice Address - Phone:386-763-2718
Practice Address - Fax:386-763-2719
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10240111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor