Healthcare Provider Details

I. General information

NPI: 1366610990
Provider Name (Legal Business Name): JOSEPH LEE RICKETSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2008
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4274 N VALDOSTA RD
VALDOSTA GA
31602-6814
US

IV. Provider business mailing address

5225 PAW PAW LN
LAKE PARK GA
31636-3182
US

V. Phone/Fax

Practice location:
  • Phone: 229-241-9288
  • Fax: 229-241-9443
Mailing address:
  • Phone: 229-563-5085
  • Fax: 229-890-3397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT013328
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: