Provider Demographics
NPI:1750437844
Name:STOCKWELL, RICHARD STANDISH JR (PT)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:STANDISH
Last Name:STOCKWELL
Suffix:JR
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 1:100 JENKINS RANCH RD
Mailing Address - Street 2:SUITE E5
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-9474
Mailing Address - Country:US
Mailing Address - Phone:970-749-5308
Mailing Address - Fax:877-460-5666
Practice Address - Street 1:100 JENKINS RANCH RD
Practice Address - Street 2:SUITE E5
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-9474
Practice Address - Country:US
Practice Address - Phone:970-749-5308
Practice Address - Fax:877-460-5666
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2925225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP4040OtherMEDICARE
CP4040OtherMEDICARE