Provider Demographics
NPI:1265620280
Name:CONNELL, RICHARD A (DOM)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:CONNELL
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 74 BOX 24813
Mailing Address - Street 2:
Mailing Address - City:EL PRADO
Mailing Address - State:NM
Mailing Address - Zip Code:87529-9533
Mailing Address - Country:US
Mailing Address - Phone:575-776-8012
Mailing Address - Fax:
Practice Address - Street 1:98 ST RD 150 VENADO PLAZA STE 5
Practice Address - Street 2:HC74 BOX 24813
Practice Address - City:EL PRADO
Practice Address - State:NM
Practice Address - Zip Code:87529
Practice Address - Country:US
Practice Address - Phone:575-776-8012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM931171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist