Provider Demographics
NPI:1356764963
Name:VILT, RICHARD JAMES
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:JAMES
Last Name:VILT
Suffix:
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 1:3727 BOSWORTH RD
Mailing Address - Street 2:OUTREACH ACADEMY
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-6037
Mailing Address - Country:US
Mailing Address - Phone:330-274-2272
Mailing Address - Fax:
Practice Address - Street 1:9772 DIAGONAL RD
Practice Address - Street 2:OUTREACH ACADEMY
Practice Address - City:MANTUA
Practice Address - State:OH
Practice Address - Zip Code:44255-9128
Practice Address - Country:US
Practice Address - Phone:330-274-2272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-03
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.017418225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist