Provider Demographics
NPI:1700579505
Name:RICHARD, BRETT S (BS, CRS, CPT)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:S
Last Name:RICHARD
Suffix:
Gender:M
Credentials:BS, CRS, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24880 BURNT PINE DR STE 8
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-4936
Mailing Address - Country:US
Mailing Address - Phone:239-206-2955
Mailing Address - Fax:
Practice Address - Street 1:24880 BURNT PINE DR STE 8
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4936
Practice Address - Country:US
Practice Address - Phone:239-206-2955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL86-2784754261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center