Provider Demographics
NPI:1962410282
Name:RICHMOND, KENT A (PT)
Entity type:Individual
Prefix:MR
First Name:KENT
Middle Name:A
Last Name:RICHMOND
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 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3909
Mailing Address - Country:US
Mailing Address - Phone:217-366-8107
Mailing Address - Fax:
Practice Address - Street 1:2110 FOX DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7553
Practice Address - Country:US
Practice Address - Phone:217-366-1323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-003703225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205364OtherMEDICARE GROUP
ILP00328904OtherRAILROAD MEDICARE
ILP00328904OtherRAILROAD MEDICARE
IL205364OtherMEDICARE GROUP
ILK12504Medicare PIN