Healthcare Provider Details

I. General information

NPI: 1265033963
Provider Name (Legal Business Name): LEE RICHARDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2020
Last Update Date: 11/08/2020
Certification Date: 11/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 A1A S STE 7
ST AUGUSTINE FL
32080-7436
US

IV. Provider business mailing address

255 OLD VILLAGE CENTER CIR UNIT 9102
SAINT AUGUSTINE FL
32084-5845
US

V. Phone/Fax

Practice location:
  • Phone: 904-679-3449
  • Fax: 904-679-3436
Mailing address:
  • Phone: 757-376-3293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number36313
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: