Provider Demographics
NPI:1841399375
Name:RICHARDSON, EDWARD WADE (DC)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:WADE
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 1:2151 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1128
Mailing Address - Country:US
Mailing Address - Phone:505-524-0400
Mailing Address - Fax:505-524-0595
Practice Address - Street 1:2151 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1128
Practice Address - Country:US
Practice Address - Phone:505-524-0400
Practice Address - Fax:505-524-0595
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM962111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK7094Medicaid
NMK7094Medicaid
NMK7094Medicaid