Healthcare Provider Details

I. General information

NPI: 1083588651
Provider Name (Legal Business Name): YOLANDA RICHESON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2025
Last Update Date: 10/06/2025
Certification Date: 10/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 E GRAND AVE APT 6
EL SEGUNDO CA
90245-4135
US

IV. Provider business mailing address

138 ARENA ST STE A
EL SEGUNDO CA
90245-3932
US

V. Phone/Fax

Practice location:
  • Phone: 310-424-8664
  • Fax:
Mailing address:
  • Phone: 310-424-8664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number64171
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: