Basic Information
| Provider Information | |||||||||
| NPI: | 1669756896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | RAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7904 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711377904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186765111 | ||||||||
| FaxNumber: | 3186765021 | ||||||||
| Practice Location | |||||||||
| Address1: | 1310 NORTH HEARNE AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186765111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2011 | ||||||||
| LastUpdateDate: | 10/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 105 | LA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.