Provider Demographics
NPI:1821584590
Name:RICHARDSON, EDRED
Entity Type:Individual
Prefix:
First Name:EDRED
Middle Name:
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 1:76 W PALISADE AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:76 W PALISADE AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2631
Practice Address - Country:US
Practice Address - Phone:201-567-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver