MEDICARE: RICHY FUECHEE VANG SR. BA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		MN

General Provider Information

NPI Number	:	1265235964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHY FUECHEE VANG SR. BA

Provider Business Mailing Address
First Line	:	11115 12TH ST N
Second Line	:
City	:	LAKE ELMO
State	:	MN
Zip	:	55042-9600
Country	:	US
Telephone Number	:	651-399-1796
Fax Number	:

Provider Business Practice Location Address
First Line	:	11115 12TH ST N
Second Line	:
City	:	LAKE ELMO
State	:	MN
Zip	:	55042-9600
Country	:	US
Telephone Number	:	651-399-1796
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2025
Last Update Date	:	03/28/2025

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