Provider Demographics
NPI:1609399641
Name:RICH, MICHAEL ALAN JR (MS, LAT, ATC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALAN
Last Name:RICH
Suffix:JR
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 LARISSA ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-6602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ONE TIGER DRIVE
Practice Address - Street 2:EAST TEXAS BAPTIST UNIVERSITY
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670
Practice Address - Country:US
Practice Address - Phone:903-923-2234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-21
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer