Healthcare Provider Details

I. General information

NPI: 1760455836
Provider Name (Legal Business Name): SAMUEL WESLEY RICHARDSON MAED, ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 06/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 COX BLVD UNIT E
SHEFFIELD AL
35660-4058
US

IV. Provider business mailing address

2346 CAMDEN CV. W.
MUSCLE SHOALS AL
35661-2346
US

V. Phone/Fax

Practice location:
  • Phone: 256-246-3490
  • Fax:
Mailing address:
  • Phone: 256-389-9029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number086
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: