Provider Demographics
NPI:1801527270
Name:EIDLITZ, RICHARD CAMERON (LMT)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:CAMERON
Last Name:EIDLITZ
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 CHESTNUT ST STE 204
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-4295
Mailing Address - Country:US
Mailing Address - Phone:910-338-9876
Mailing Address - Fax:
Practice Address - Street 1:411 CHESTNUT ST STE 204
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-4295
Practice Address - Country:US
Practice Address - Phone:910-338-9876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2038225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist