Provider Demographics
NPI:1992149249
Name:RICHARDS, SAMUEL WALLACE (DC)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:WALLACE
Last Name:RICHARDS
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 1:921 39TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-5924
Mailing Address - Country:US
Mailing Address - Phone:727-647-4521
Mailing Address - Fax:
Practice Address - Street 1:6535 4TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-6813
Practice Address - Country:US
Practice Address - Phone:727-289-9148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10750111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor