Basic Information
| Provider Information | |||||||||
| NPI: | 1265033963 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICHARDS | ||||||||
| FirstName: | LEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 OLD VILLAGE CENTER CIR UNIT 9102 | ||||||||
| Address2: | |||||||||
| City: | SAINT AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320845845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573763293 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4320 A1A S STE 7 | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320807436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046793449 | ||||||||
| FaxNumber: | 9046793436 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2020 | ||||||||
| LastUpdateDate: | 11/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 36313 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.