Provider Demographics
NPI:1124477443
Name:RICHMOND, HEATHER (LAC DAOM)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:
Last Name:RICHMOND
Suffix:
Gender:F
Credentials:LAC DAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2112
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80306-2112
Mailing Address - Country:US
Mailing Address - Phone:303-444-4790
Mailing Address - Fax:
Practice Address - Street 1:908 MAIN ST STE B104
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-1867
Practice Address - Country:US
Practice Address - Phone:303-444-4790
Practice Address - Fax:720-598-6121
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0002080171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0431938Medicaid