Healthcare Provider Details

I. General information

NPI: 1770587651
Provider Name (Legal Business Name): STANLEY MILTON RICE PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 S LANDMARK AVE
BLOOMINGTON IN
47403-5003
US

IV. Provider business mailing address

421 S LANDMARK AVE
BLOOMINGTON IN
47403-5003
US

V. Phone/Fax

Practice location:
  • Phone: 812-332-4468
  • Fax: 812-331-3311
Mailing address:
  • Phone: 812-332-4468
  • Fax: 812-331-3311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10000131A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: