Provider Demographics
NPI:1588348536
Name:RICHARDSON, KESHA
Entity type:Individual
Prefix:
First Name:KESHA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6023 W AVENUE L12
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-3742
Mailing Address - Country:US
Mailing Address - Phone:661-579-6699
Mailing Address - Fax:661-522-7831
Practice Address - Street 1:6023 W AVENUE L12
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-3742
Practice Address - Country:US
Practice Address - Phone:661-579-6699
Practice Address - Fax:661-522-7831
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA197610169310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility