Provider Demographics
NPI:1255529483
Name:DURELL, RICHARD DARIN (PT)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:DARIN
Last Name:DURELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5041 DALLAS HWY
Mailing Address - Street 2:BLDG 1, SUITE C
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-6458
Mailing Address - Country:US
Mailing Address - Phone:770-425-2151
Mailing Address - Fax:770-425-5982
Practice Address - Street 1:5041 DALLAS HWY
Practice Address - Street 2:BLDG 1, SUITE C
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-6458
Practice Address - Country:US
Practice Address - Phone:770-425-2151
Practice Address - Fax:770-425-5982
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007058225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBCHNMedicare PIN