=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285814657
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GLEN ADAM RICHARDSON ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2007
-----------------------------------------------------
Last Update Date | 11/13/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 LORETTO RD SPRING VIEW REHABILITATION SERVICES
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40033-1300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-692-5130
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 LORETTO RD SPRING VIEW REHABILITATION SERVICES
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40033-1300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-692-5130
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT501
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------