Provider Demographics
NPI:1104393990
Name:PEARCEY, RICHARD MARTIN
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:MARTIN
Last Name:PEARCEY
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 1:2480 MACIEL LN
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-8633
Mailing Address - Country:US
Mailing Address - Phone:707-218-7961
Mailing Address - Fax:707-464-6316
Practice Address - Street 1:2480 MACIEL LN
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-8633
Practice Address - Country:US
Practice Address - Phone:707-218-7961
Practice Address - Fax:707-464-6316
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN8178999172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty