MEDICARE: DR. RICKY LYNN PETHERS DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2301002936	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	950A55010	OTHER	MI	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1982700456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICKY LYNN PETHERS DC

Provider Business Mailing Address
First Line	:	430 BOYNE AVE
Second Line	:
City	:	BOYNE CITY
State	:	MI
Zip	:	49712-1263
Country	:	US
Telephone Number	:	231-582-6581
Fax Number	:	231-582-6449

Provider Business Practice Location Address
First Line	:	430 BOYNE AVE
Second Line	:
City	:	BOYNE CITY
State	:	MI
Zip	:	49712-1263
Country	:	US
Telephone Number	:	231-582-6581
Fax Number	:	231-582-6449

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	07/08/2007

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