Provider Demographics
NPI:1942943063
Name:ROBERTSON, RICHARD K JR
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:K
Last Name:ROBERTSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15813 WALVERN BLVD
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-4652
Mailing Address - Country:US
Mailing Address - Phone:216-224-1223
Mailing Address - Fax:
Practice Address - Street 1:5592 DALEWOOD AVE
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-3436
Practice Address - Country:US
Practice Address - Phone:216-224-1223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-16
Last Update Date:2022-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH602443510122376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide