Provider Demographics
NPI:1871703314
Name:RICHMOND, JACKIE DAVID (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:JACKIE
Middle Name:DAVID
Last Name:RICHMOND
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 MIDWESTERN PARKWAY
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-2835
Mailing Address - Country:US
Mailing Address - Phone:940-692-3754
Mailing Address - Fax:
Practice Address - Street 1:3010 MIDWESTERN PARKWAY
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2835
Practice Address - Country:US
Practice Address - Phone:940-692-3754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3986150001Medicare ID - Type UnspecifiedOPTICIAN