Healthcare Provider Details

I. General information

NPI: 1336057744
Provider Name (Legal Business Name): FRED WILEY RICHARDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 INDIAN VIEW RD
GLORIETA NM
87535-7187
US

IV. Provider business mailing address

34 INDIAN VIEW RD
GLORIETA NM
87535-7187
US

V. Phone/Fax

Practice location:
  • Phone: 505-316-1654
  • Fax:
Mailing address:
  • Phone: 505-316-1654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code342000000X
TaxonomyTransportation Network Company
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: