=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063779403
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DUSTIN RICHERT PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2012
-----------------------------------------------------
Last Update Date | 04/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 HARTMAN LN STE 500
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269-1783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-589-9000
-----------------------------------------------------
Fax | 618-589-9005
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 APEX DR
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62249-1282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-589-9000
-----------------------------------------------------
Fax | 618-589-9005
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 070.016295
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------