Provider Demographics
NPI:1285618702
Name:MOONEYHAM, RICHARD SCOTT (PT)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:SCOTT
Last Name:MOONEYHAM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1823 SHAW AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-4064
Mailing Address - Country:US
Mailing Address - Phone:559-298-9120
Mailing Address - Fax:559-298-0822
Practice Address - Street 1:1823 SHAW AVE
Practice Address - Street 2:STE 101
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-4065
Practice Address - Country:US
Practice Address - Phone:559-298-9120
Practice Address - Fax:559-298-0822
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT22252225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEO581ZMedicare PIN