=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457429342
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD L WATSON P.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | HPRC 30A&B SAMFORD AVE
-----------------------------------------------------
City | OPELIKA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-742-9266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1625 CRESCENT BLVD
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36830-2578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-501-2169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | PTH4365
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------