Healthcare Provider Details

I. General information

NPI: 1861446858
Provider Name (Legal Business Name): CHARLES E RICKARD JR FNP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 05/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 W PARK PL
HENDERSON TN
38340-2027
US

IV. Provider business mailing address

557 W PARK PL
HENDERSON TN
38340-2027
US

V. Phone/Fax

Practice location:
  • Phone: 731-989-1007
  • Fax: 731-989-0704
Mailing address:
  • Phone: 731-989-1007
  • Fax: 731-989-0704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number44-3960
License Number StateTN

VIII. Authorized Official

Name: MR. CHARLES E RICKARD JR.
Title or Position: OWNER
Credential: FNP,MSN,APN,BC
Phone: 731-989-1007