Healthcare Provider Details

I. General information

NPI: 1033215249
Provider Name (Legal Business Name): RICHARD KINGSTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N MAIN ST WYOMING COUNTY COMMUNITY HOSPITAL
WARSAW NY
14569-1025
US

IV. Provider business mailing address

12174 CENTERLINE RD
SOUTH WALES NY
14139-9755
US

V. Phone/Fax

Practice location:
  • Phone: 585-786-2233
  • Fax: 585-786-1275
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number016362-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: