Healthcare Provider Details

I. General information

NPI: 1568931707
Provider Name (Legal Business Name): EDWIN RICHARDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2018
Last Update Date: 11/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 SQUIRRELS NEST LN
VILLA RICA GA
30180-4162
US

IV. Provider business mailing address

4600 SQUIRRELS NEST LN
VILLA RICA GA
30180-4162
US

V. Phone/Fax

Practice location:
  • Phone: 678-576-2989
  • Fax:
Mailing address:
  • Phone: 678-576-2989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code332BD1200X
TaxonomyDialysis Equipment & Supplies (DME)
License Number
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: