MEDICARE: RICHARD PEEBLES III

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	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1326931189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD PEEBLES III

Provider Business Mailing Address
First Line	:	7908 MOSS GATE TER
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23227-1672
Country	:	US
Telephone Number	:	804-426-1113
Fax Number	:

Provider Business Practice Location Address
First Line	:	4243 LLEWELLYN AVE APT 203
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23504-1133
Country	:	US
Telephone Number	:	804-426-1113
Fax Number	:

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

Provider Enumeration Date	:	05/30/2025
Last Update Date	:	05/30/2025

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