1124504386 NPI number — CHEYENNE LOUISE RICHARDS RDN, LD, MBA

Table of content: CHEYENNE LOUISE RICHARDS RDN, LD, MBA (NPI 1124504386)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124504386 NPI number — CHEYENNE LOUISE RICHARDS RDN, LD, MBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RICHARDS
Provider First Name:
CHEYENNE
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RDN, LD, MBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARTIN
Provider Other First Name:
CHEYENNE
Provider Other Middle Name:
LOUISE-BRYANT
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124504386
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1007 JOHNNIE DODDS BLVD STE 117
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT PLEASANT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29464-6123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-580-8354
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 FAYE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT PLEASANT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29464-6626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-695-0769
Provider Business Practice Location Address Fax Number:
843-972-8914
Provider Enumeration Date:
07/11/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  1580 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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