Provider Demographics
NPI:1881400802
Name:CEFALU, RICHARD JOSEPH (LMT 2859)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOSEPH
Last Name:CEFALU
Suffix:
Gender:M
Credentials:LMT 2859
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8837 LORRAINE RD STE A
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-5081
Mailing Address - Country:US
Mailing Address - Phone:228-239-6865
Mailing Address - Fax:
Practice Address - Street 1:8837 LORRAINE RD STE A
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-5081
Practice Address - Country:US
Practice Address - Phone:228-239-6865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2859225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist