MEDICARE: RICHARD LOUIS 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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1750635181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD LOUIS III

Provider Business Mailing Address
First Line	:	4929 WILSHIRE BLVD STE 510
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-3820
Country	:	US
Telephone Number	:	310-734-5579
Fax Number	:	310-734-5511

Provider Business Practice Location Address
First Line	:	4929 WILSHIRE BLVD STE 510
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-3820
Country	:	US
Telephone Number	:	310-734-5579
Fax Number	:	310-734-5511

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

Provider Enumeration Date	:	11/07/2012
Last Update Date	:	11/07/2012

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