Provider Demographics
NPI:1114912110
Name:BEDDOE, RICHARD LEROY
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:LEROY
Last Name:BEDDOE
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 1:311 LUCE AVE
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5667
Mailing Address - Country:US
Mailing Address - Phone:707-463-2500
Mailing Address - Fax:
Practice Address - Street 1:311 LUCE AVE
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5667
Practice Address - Country:US
Practice Address - Phone:707-463-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13275225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4449135Medicaid
CAOPT132750Medicare ID - Type UnspecifiedMEDICARE
CA4449135Medicaid