Healthcare Provider Details

I. General information

NPI: 1083061097
Provider Name (Legal Business Name): RICKELS FAMILY PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304B BRENDA AVE
PERRYVILLE MO
63775-2303
US

IV. Provider business mailing address

1304B BRENDA AVE
PERRYVILLE MO
63775-2303
US

V. Phone/Fax

Practice location:
  • Phone: 573-547-8300
  • Fax: 573-547-8329
Mailing address:
  • Phone: 573-547-8300
  • Fax: 573-547-8329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2016002493
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. RENATA RUDI RICKELS
Title or Position: OWNER
Credential: D.C.
Phone: 573-547-8300