=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215623178
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD ERICKSON CAPA LPN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2023
-----------------------------------------------------
Last Update Date | 04/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8207 22ND AVE
-----------------------------------------------------
City | KENOSHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53143-6206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-653-9286
-----------------------------------------------------
Fax | 224-610-2601
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18608 W MAIN ST
-----------------------------------------------------
City | GAGES LAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60030-1755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-912-3715
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 043.117020
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------