Provider Demographics
NPI:1275543712
Name:RICHARDS, CHARLES HERBERT
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:HERBERT
Last Name:RICHARDS
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 1:429 D ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-5706
Mailing Address - Country:US
Mailing Address - Phone:530-742-1679
Mailing Address - Fax:530-742-1233
Practice Address - Street 1:429 D ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-5706
Practice Address - Country:US
Practice Address - Phone:530-742-1679
Practice Address - Fax:530-742-1233
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7038T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0070380Medicaid
T10459Medicare UPIN
CA0257470002Medicare NSC
CASD0070380Medicaid
CA410008995Medicare PIN
CASD0070381Medicare ID - Type Unspecified