Healthcare Provider Details

I. General information

NPI: 1740378785
Provider Name (Legal Business Name): KENNETH RICHARDS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N MARKET ST
MILAN MO
63556-1316
US

IV. Provider business mailing address

210 N MARKET ST
MILAN MO
63556-1316
US

V. Phone/Fax

Practice location:
  • Phone: 660-265-4456
  • Fax: 660-265-4627
Mailing address:
  • Phone: 660-265-4456
  • Fax: 660-265-4627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number109328
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: