Healthcare Provider Details

I. General information

NPI: 1275861734
Provider Name (Legal Business Name): PHILLIP OLIVER RICHARDS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2009
Last Update Date: 11/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45546 APPIAN WAY
INDIAN WELLS CA
92210-6150
US

IV. Provider business mailing address

45546 APPIAN WAY
INDIAN WELLS CA
92210-6150
US

V. Phone/Fax

Practice location:
  • Phone: 760-345-8904
  • Fax: 760-345-8510
Mailing address:
  • Phone: 760-345-8904
  • Fax: 760-345-8510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number4301029346
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: