Healthcare Provider Details

I. General information

NPI: 1063030062
Provider Name (Legal Business Name): RICHARDSON PROSTHETICS & ORTHOTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 PROSPERITY CHURCH RD STE 101
CHARLOTTE NC
28269-8194
US

IV. Provider business mailing address

3210 PROSPERITY CHURCH RD STE 101
CHARLOTTE NC
28269-8194
US

V. Phone/Fax

Practice location:
  • Phone: 704-510-2204
  • Fax:
Mailing address:
  • Phone: 704-510-2204
  • Fax: 704-510-2218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: RONDELL RICHARDSON
Title or Position: OWNER
Credential: CO, BOCP
Phone: 704-510-2204