Healthcare Provider Details

I. General information

NPI: 1326032392
Provider Name (Legal Business Name): GLENN L. RICHARDSON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: LARRY RICHARDSON PT

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 CHRISTIAN DR BOX 834
RAYVILLE LA
71269-3645
US

IV. Provider business mailing address

950 HIGHWAY 584
RAYVILLE LA
71269-4328
US

V. Phone/Fax

Practice location:
  • Phone: 318-728-4088
  • Fax: 318-728-4124
Mailing address:
  • Phone: 318-728-8879
  • Fax: 318-728-8879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLA 03589
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: