Healthcare Provider Details

I. General information

NPI: 1912012782
Provider Name (Legal Business Name): RICKY D SYPERT OT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4642 N LOOP 289 SUITE 219
LUBBOCK TX
79416
US

IV. Provider business mailing address

4642 N LOOP 289 SUITE 219
LUBBOCK TX
79416
US

V. Phone/Fax

Practice location:
  • Phone: 806-795-7762
  • Fax: 806-796-7168
Mailing address:
  • Phone: 806-795-7762
  • Fax: 806-796-7168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number103802
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: