Provider Demographics
NPI:1023016813
Name:KUPCHO, RICHARD A (DC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:KUPCHO
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 1:2715 SE MORNINGSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5705
Mailing Address - Country:US
Mailing Address - Phone:772-337-4611
Mailing Address - Fax:772-337-4611
Practice Address - Street 1:2715 SE MORNINGSIDE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5705
Practice Address - Country:US
Practice Address - Phone:772-337-4611
Practice Address - Fax:772-337-4619
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006294111N00000X
FLCH6447111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
11319830OtherCAQH
FLCH6447OtherSTATE LICENSE
IL921210Medicaid