MEDICARE: MR. RICHARD ENDERLIN IV

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171400000X	Health & Wellness Coach	A-3939425	VT

General Provider Information

NPI Number	:	1700612553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICHARD ENDERLIN IV

Provider Business Mailing Address
First Line	:	PO BOX 98
Second Line	:
City	:	TAFTSVILLE
State	:	VT
Zip	:	05073-0098
Country	:	US
Telephone Number	:	310-855-4470
Fax Number	:

Provider Business Practice Location Address
First Line	:	2588 E WOODSTOCK RD
Second Line	:
City	:	WOODSTOCK
State	:	VT
Zip	:	05091-3661
Country	:	US
Telephone Number	:	310-855-4470
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2024
Last Update Date	:	09/10/2024

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