Provider Demographics
NPI:1770251456
Name:BALLARD, RICHARD ALLEN (AT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLEN
Last Name:BALLARD
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16265 MCKENZIE GRADE
Mailing Address - Street 2:
Mailing Address - City:GEORGIANA
Mailing Address - State:AL
Mailing Address - Zip Code:36033-5836
Mailing Address - Country:US
Mailing Address - Phone:334-453-1120
Mailing Address - Fax:
Practice Address - Street 1:1147 US-231 STE 9 & 10
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:AL
Practice Address - Zip Code:36081
Practice Address - Country:US
Practice Address - Phone:334-465-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer