=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851441760
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRUCE W. RICKER D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2007
-----------------------------------------------------
Last Update Date | 11/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 504 N. CLEVELAND ST.
-----------------------------------------------------
City | MOUNT AYR
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50854-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-464-3226
-----------------------------------------------------
Fax | 641-464-4420
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 504 N. CLEVELAND ST.
-----------------------------------------------------
City | MOUNT AYR
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50854-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-464-3226
-----------------------------------------------------
Fax | 641-464-4420
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 02962
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------