Healthcare Provider Details

I. General information

NPI: 1992759658
Provider Name (Legal Business Name): TRACY WADE RICHARDSON D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 12/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 PUBLIC SQUARE EAST
WAYNESBORO TN
38485
US

IV. Provider business mailing address

480 COUNTY ROAD 298
FLORENCE AL
35634-5148
US

V. Phone/Fax

Practice location:
  • Phone: 931-722-7090
  • Fax: 931-722-7090
Mailing address:
  • Phone: 256-443-1558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2100
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: