Provider Demographics
NPI:1215952429
Name:RICHARDS, LESLIE (RD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1241 JOHNSON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3306
Mailing Address - Country:US
Mailing Address - Phone:805-541-2300
Mailing Address - Fax:805-541-2301
Practice Address - Street 1:1318 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3314
Practice Address - Country:US
Practice Address - Phone:805-541-2300
Practice Address - Fax:805-541-2301
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA508178133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB209886OtherMEDICARE PTAN
CACB209886OtherMEDICARE PTAN
MNT508178Medicare UPIN