Provider Demographics
NPI:1003438540
Name:RICHARDSON, NICHLOS ARLEN (PTA)
Entity type:Individual
Prefix:
First Name:NICHLOS
Middle Name:ARLEN
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CURTIS LN
Mailing Address - Street 2:
Mailing Address - City:HOWE
Mailing Address - State:TX
Mailing Address - Zip Code:75459-3698
Mailing Address - Country:US
Mailing Address - Phone:760-912-6709
Mailing Address - Fax:
Practice Address - Street 1:110 CURTIS LN
Practice Address - Street 2:
Practice Address - City:HOWE
Practice Address - State:TX
Practice Address - Zip Code:75459-3698
Practice Address - Country:US
Practice Address - Phone:760-912-6709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2136640208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation