Healthcare Provider Details

I. General information

NPI: 1811485337
Provider Name (Legal Business Name): RICHARD W BRAINERD III ATC, LAT, MS.ED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18220 STATE HIGHWAY 249
HOUSTON TX
77070-4347
US

IV. Provider business mailing address

7250 W GREENS RD APT 614
HOUSTON TX
77064-1126
US

V. Phone/Fax

Practice location:
  • Phone: 631-455-1862
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT7193
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: