Provider Demographics
NPI:1932372414
Name:URDIALES, RICHARD R (LPT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:R
Last Name:URDIALES
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:1123 N MAIN AVE
Practice Address - Street 2:STE 211
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-4738
Practice Address - Country:US
Practice Address - Phone:210-226-2101
Practice Address - Fax:210-226-6445
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1084473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX650508OtherMEDICARE PROVIDER NUMBER