Healthcare Provider Details

I. General information

NPI: 1033215843
Provider Name (Legal Business Name): MR. DAVE RITTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 E LEAFLAND AVE
DECATUR IL
62521-1020
US

IV. Provider business mailing address

135 W MAIN ST
MT ZION IL
62549-1543
US

V. Phone/Fax

Practice location:
  • Phone: 217-423-4466
  • Fax: 217-423-9461
Mailing address:
  • Phone: 217-423-4466
  • Fax: 217-423-9461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: