Provider Demographics
NPI:1770223943
Name:RICHARDSON, SCOTT THOMAS JR
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:THOMAS
Last Name:RICHARDSON
Suffix:JR
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 1:6755 CHIEFTAIN DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-5804
Mailing Address - Country:US
Mailing Address - Phone:505-274-2504
Mailing Address - Fax:
Practice Address - Street 1:757 WESTWOOD PLZ
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-8358
Practice Address - Country:US
Practice Address - Phone:310-825-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program