Provider Demographics
NPI:1083610018
Name:RICHARDS, KEN EH (PT)
Entity Type:Individual
Prefix:MR
First Name:KEN
Middle Name:EH
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11268 VOLLMER DR
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-4874
Mailing Address - Country:US
Mailing Address - Phone:951-317-1301
Mailing Address - Fax:
Practice Address - Street 1:5725 RALSTON ST
Practice Address - Street 2:STE 103
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6053
Practice Address - Country:US
Practice Address - Phone:805-658-6964
Practice Address - Fax:805-477-0370
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT0188620174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT118620AOtherMEDICARE ID
CAPT0118620Medicare UPIN