Provider Demographics
NPI:1396405916
Name:GOMEZ, RICHARD LUDWIG
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:LUDWIG
Last Name:GOMEZ
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 1:5401 NETHERBY LN # 901
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29420-7363
Mailing Address - Country:US
Mailing Address - Phone:843-603-1613
Mailing Address - Fax:
Practice Address - Street 1:5401 NETHERBY LN UNIT 901
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-7363
Practice Address - Country:US
Practice Address - Phone:843-603-1613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-22
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12645225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist