Healthcare Provider Details

I. General information

NPI: 1548727977
Provider Name (Legal Business Name): RAYMOND RICHARDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 KINGSLAND ST
NUTLEY NJ
07110-1150
US

IV. Provider business mailing address

25 MANOR DR APT 14N
NEWARK NJ
07106-3248
US

V. Phone/Fax

Practice location:
  • Phone: 973-761-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: