Healthcare Provider Details

I. General information

NPI: 1538649991
Provider Name (Legal Business Name): RICHARD LEE WISE II RCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 MAGNOLIA AVE
RIVERSIDE CA
92505-3043
US

IV. Provider business mailing address

33201 WINDTREE AVE
WILDOMAR CA
92595-8235
US

V. Phone/Fax

Practice location:
  • Phone: 951-353-4480
  • Fax:
Mailing address:
  • Phone: 909-674-4937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279C0205X
TaxonomyCritical Care Registered Respiratory Therapist
License NumberRCP7097
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: