MEDICARE: MR. JERRY D RICHARDS BC-HIS,ACA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	237700000X	Hearing Instrument Specialist	391	AR

General Provider Information

NPI Number	:	1902013485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JERRY D RICHARDS BC-HIS,ACA

Provider Business Mailing Address
First Line	:	1005 LEXINGTON AVE
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72901-4945
Country	:	US
Telephone Number	:	479-783-5250
Fax Number	:	479-782-9629

Provider Business Practice Location Address
First Line	:	1005 LEXINGTON AVE
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72901-4945
Country	:	US
Telephone Number	:	479-783-5250
Fax Number	:	479-782-9629

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	07/08/2007

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