Provider Demographics
NPI:1295759751
Name:RICHARDS, GREGG RANDALL (RPT)
Entity type:Individual
Prefix:
First Name:GREGG
Middle Name:RANDALL
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 W LINE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-3347
Mailing Address - Country:US
Mailing Address - Phone:760-873-7230
Mailing Address - Fax:760-872-3418
Practice Address - Street 1:512 W LINE ST
Practice Address - Street 2:SUITE C
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-3347
Practice Address - Country:US
Practice Address - Phone:760-873-7230
Practice Address - Fax:760-872-3418
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00PT66310225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT66310Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER