Healthcare Provider Details

I. General information

NPI: 1093552630
Provider Name (Legal Business Name): TYLER RICHARDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2024
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 ASHLEY AVE
CHARLESTON SC
29425-0100
US

IV. Provider business mailing address

605 TRIO LN
SUMMERVILLE SC
29486-5442
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-1414
  • Fax:
Mailing address:
  • Phone: 803-741-6378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number240296
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: