Healthcare Provider Details

I. General information

NPI: 1609347137
Provider Name (Legal Business Name): WILLIE D RICHARDSON SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2018
Last Update Date: 12/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8316 MACON TER STE 102
CORDOVA TN
38018-8505
US

IV. Provider business mailing address

8316 MACON TER STE 102
CORDOVA TN
38018-8505
US

V. Phone/Fax

Practice location:
  • Phone: 901-624-0371
  • Fax: 901-624-0375
Mailing address:
  • Phone: 901-624-0371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberL000000022609
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierQ018034
Identifier TypeMEDICAID
Identifier StateTN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: