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General NPI Number Information
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NPI Number | 1790147908
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Entity Type | Organization
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Legal Business Name | RICHARD WA RICKMAN LLC
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Dates
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Enumeration Date | 03/26/2016
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Last Update Date | 05/23/2016
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Provider Practice Location Address
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Address Line | 2804 N OAK ST SUITE A
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City | VALDOSTA
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State | GA
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Zip | 31602-5914
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Country | US
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Telephone | 229-469-7730
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Fax | 229-469-7729
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Provider Business Mailing Address
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Address Line | 2804 N OAK ST SUITE A
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City | VALDOSTA
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State | GA
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Zip | 31602-5914
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Country | US
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Telephone | 229-469-7730
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Fax | 229-469-7729
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Authorized Official
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Title or Position | MEDICAL DOCTOR
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Name | DR. RICHARD RICKMAN
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Credential | M.D.
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Telephone | 229-469-7729
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 049332
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License Number State | GA
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