Provider Demographics
NPI:1720057086
Name:PACKO, RICHARD G (DC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:G
Last Name:PACKO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:R.
Other - Middle Name:G
Other - Last Name:PACKO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:252 SOLANA RD
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2297
Mailing Address - Country:US
Mailing Address - Phone:904-285-2243
Mailing Address - Fax:904-285-9022
Practice Address - Street 1:252 SOLANA RD
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-2297
Practice Address - Country:US
Practice Address - Phone:904-285-2243
Practice Address - Fax:904-285-9022
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0006259111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU-17369Medicare UPIN
FL55308Medicare ID - Type Unspecified