Healthcare Provider Details

I. General information

NPI: 1326700113
Provider Name (Legal Business Name): KRYSTAL RENNEE RICHARDS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2021
Last Update Date: 10/08/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 N CALIFORNIA ST STE 17
STOCKTON CA
95202-2130
US

IV. Provider business mailing address

425 N CALIFORNIA ST STE 17
STOCKTON CA
95202-2130
US

V. Phone/Fax

Practice location:
  • Phone: 209-870-5000
  • Fax:
Mailing address:
  • Phone: 209-870-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86198913
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: