Provider Demographics
NPI:1104499821
Name:EDWARDS, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 SHELL RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23661-2447
Mailing Address - Country:US
Mailing Address - Phone:757-696-1652
Mailing Address - Fax:
Practice Address - Street 1:1816 SHELL RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23661-2447
Practice Address - Country:US
Practice Address - Phone:757-696-1652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1301090782247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other