Healthcare Provider Details

I. General information

NPI: 1356463756
Provider Name (Legal Business Name): CYNTHIA JENE RICHARDSON HOME CARE PROVIDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 WAMPLER AVE
DAYTON OH
45405-5122
US

IV. Provider business mailing address

36 WAMPLER AVE
DAYTON OH
45405-5122
US

V. Phone/Fax

Practice location:
  • Phone: 937-278-3473
  • Fax:
Mailing address:
  • Phone: 937-278-3473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number2402251
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: