Healthcare Provider Details

I. General information

NPI: 1851692891
Provider Name (Legal Business Name): DDMR PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 11/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 E SUNSET DR
MONROE NC
28112-4324
US

IV. Provider business mailing address

420 UTILITY DR
CLEMMONS NC
27012-8397
US

V. Phone/Fax

Practice location:
  • Phone: 704-296-9090
  • Fax:
Mailing address:
  • Phone: 336-766-5935
  • Fax: 336-766-5365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number3062
License Number StateNC

VIII. Authorized Official

Name: DR. MICHAEL RICCOBONI
Title or Position: ORGANIZING MEMBER
Credential: D.C.
Phone: 336-766-5935