Healthcare Provider Details

I. General information

NPI: 1003438540
Provider Name (Legal Business Name): NICHLOS ARLEN RICHARDSON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CURTIS LN
HOWE TX
75459-3698
US

IV. Provider business mailing address

110 CURTIS LN
HOWE TX
75459-3698
US

V. Phone/Fax

Practice location:
  • Phone: 760-912-6709
  • Fax:
Mailing address:
  • Phone: 760-912-6709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2136640
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: