Provider Demographics
NPI:1528412186
Name:RICHARDSON, CEDRIC R
Entity Type:Individual
Prefix:
First Name:CEDRIC
Middle Name:R
Last Name:RICHARDSON
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 COMMERCIAL DR APT 20
Mailing Address - Street 2:
Mailing Address - City:PORT ALLEN
Mailing Address - State:LA
Mailing Address - Zip Code:70767-6183
Mailing Address - Country:US
Mailing Address - Phone:225-439-8638
Mailing Address - Fax:
Practice Address - Street 1:2480 COMMERCIAL DR APT 20
Practice Address - Street 2:
Practice Address - City:PORT ALLEN
Practice Address - State:LA
Practice Address - Zip Code:70767-6183
Practice Address - Country:US
Practice Address - Phone:225-439-8638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6421917172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver