Healthcare Provider Details

I. General information

NPI: 1396342556
Provider Name (Legal Business Name): MR. RALPH CHISTOPHER RUCKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11395 LANC KIRK RD NW
BALTIMORE OH
43105-9630
US

IV. Provider business mailing address

PO BOX 221
BALTIMORE OH
43105-0221
US

V. Phone/Fax

Practice location:
  • Phone: 614-203-1695
  • Fax:
Mailing address:
  • Phone: 161-420-3169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number0114821
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: