Provider Demographics
NPI:1992759658
Name:RICHARDSON, TRACY WADE (DC)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:WADE
Last Name:RICHARDSON
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 1:480 COUNTY ROAD 298
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35634-5148
Mailing Address - Country:US
Mailing Address - Phone:256-443-1558
Mailing Address - Fax:
Practice Address - Street 1:120 PUBLIC SQUARE EAST
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:TN
Practice Address - Zip Code:38485
Practice Address - Country:US
Practice Address - Phone:931-722-7090
Practice Address - Fax:931-722-7090
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2100111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL65689Medicare UPIN