Provider Demographics
NPI:1285796359
Name:RICHARDSON, JOHN DAVID (DC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
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 349
Mailing Address - Street 2:
Mailing Address - City:SAN ANDREAS
Mailing Address - State:CA
Mailing Address - Zip Code:95249-0349
Mailing Address - Country:US
Mailing Address - Phone:209-754-1881
Mailing Address - Fax:209-754-5154
Practice Address - Street 1:134 E ST CHARLES
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249
Practice Address - Country:US
Practice Address - Phone:209-754-1881
Practice Address - Fax:209-754-5154
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA016030111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor