Healthcare Provider Details

I. General information

NPI: 1528237492
Provider Name (Legal Business Name): RIKA MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2008
Last Update Date: 12/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6131 S NORCROSS TUCKER RD SUITE 6
NORCROSS GA
30093-5536
US

IV. Provider business mailing address

150 MEDICAL BLVD SUITE C
STOCKBRIDGE GA
30281-5053
US

V. Phone/Fax

Practice location:
  • Phone: 678-205-1959
  • Fax: 678-205-2092
Mailing address:
  • Phone: 678-289-4920
  • Fax: 678-289-4942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number050585
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27368
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number26530
License Number StateGA

VIII. Authorized Official

Name: MR. RAVI REDDY MANCHIREDDY
Title or Position: OWNER
Credential: MR
Phone: 678-289-4920