Healthcare Provider Details

I. General information

NPI: 1760650980
Provider Name (Legal Business Name): RICHARDSON FAMILY HEALTH CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 04/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 BROADWAY ST
ROCK SPRINGS WY
82901-6269
US

IV. Provider business mailing address

430 BROADWAY ST
ROCK SPRINGS WY
82901-6269
US

V. Phone/Fax

Practice location:
  • Phone: 307-382-8668
  • Fax:
Mailing address:
  • Phone: 307-382-8668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number4012A
License Number StateWY

VIII. Authorized Official

Name: CHARLES ALAN RICHARDSON
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: MD
Phone: 307-382-8668