=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235543802
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIKARDS RESIDENTIAL FAMILY CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2014
-----------------------------------------------------
Last Update Date | 06/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1628 DUNBAR ST
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27401-3806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-772-2491
-----------------------------------------------------
Fax | 336-373-3962
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1628 DUNBAR ST
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27401-3806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-772-2491
-----------------------------------------------------
Fax | 336-373-3962
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MARYANN MACK RIKARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-772-2491
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------