Provider Demographics
NPI:1386419596
Name:RICHMOND, MATTHEW VAUGHN TERRENCE
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:VAUGHN TERRENCE
Last Name:RICHMOND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 SALEM RD
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-4551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3505 SALEM RD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-4551
Practice Address - Country:US
Practice Address - Phone:229-291-4946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR010608111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor