Healthcare Provider Details

I. General information

NPI: 1710071014
Provider Name (Legal Business Name): RICHARD E COMELLO CMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 02/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8202 EXCELSIOR DR
MADISON WI
53717-1906
US

IV. Provider business mailing address

1265 JOHN Q HAMMONS DR
MADISON WI
53717-1941
US

V. Phone/Fax

Practice location:
  • Phone: 608-831-1766
  • Fax:
Mailing address:
  • Phone: 608-251-4156
  • Fax: 608-278-1695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3055-046
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: