Basic Information
| Provider Information | |||||||||
| NPI: | 1609844158 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | MIKEL | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 288 DUE WEST DR | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302816211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785650542 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1275 HIGHWAY 54 W | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302144549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704611238 | ||||||||
| FaxNumber: | 7704618012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 000559 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.