Provider Demographics
NPI:1932955473
Name:RICHARDSON, AZIBO SALI SR
Entity Type:Individual
Prefix:
First Name:AZIBO
Middle Name:SALI
Last Name:RICHARDSON
Suffix:SR
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 1:1010 HELEN POWER DR # 1057
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-3504
Mailing Address - Country:US
Mailing Address - Phone:702-235-1295
Mailing Address - Fax:
Practice Address - Street 1:3501 HARBISON DR UNIT 307
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-3932
Practice Address - Country:US
Practice Address - Phone:702-235-1295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38751225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist