Provider Demographics
NPI:1013663764
Name:RICHBERG, TANNER (MS, CSCS, CEP)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:RICHBERG
Suffix:
Gender:M
Credentials:MS, CSCS, CEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 GRACELAND DR
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-2516
Mailing Address - Country:US
Mailing Address - Phone:843-531-2957
Mailing Address - Fax:
Practice Address - Street 1:9051 PALMETTO COMMERCE PKWY
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-6705
Practice Address - Country:US
Practice Address - Phone:843-695-2205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10657252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer