Provider Demographics
NPI:1063867216
Name:WLADICH, RICHARD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WLADICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12901 VENICE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3509
Mailing Address - Country:US
Mailing Address - Phone:310-390-3611
Mailing Address - Fax:310-390-4906
Practice Address - Street 1:12901 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066
Practice Address - Country:US
Practice Address - Phone:310-390-3611
Practice Address - Fax:310-390-4906
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator