=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609351253
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICKY CHARLES MERRIAM LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2018
-----------------------------------------------------
Last Update Date | 09/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12700 HILLCREST RD STE 125 #143
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75230-2009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-307-1729
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12700 HILLCREST RD STE 125 #143
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75230-2009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-307-1729
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 110566
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------