Provider Demographics
NPI:1194909119
Name:RICHARDSON, DAMIAN SETH (DC)
Entity type:Individual
Prefix:DR
First Name:DAMIAN
Middle Name:SETH
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DC
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 123
Mailing Address - Street 2:
Mailing Address - City:CREEDE
Mailing Address - State:CO
Mailing Address - Zip Code:81130-0123
Mailing Address - Country:US
Mailing Address - Phone:719-658-3079
Mailing Address - Fax:
Practice Address - Street 1:493 S. MAIN STREET
Practice Address - Street 2:
Practice Address - City:CREEDE
Practice Address - State:CO
Practice Address - Zip Code:81130
Practice Address - Country:US
Practice Address - Phone:719-658-0526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5177111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO460018Medicare PIN