MEDICARE: MR. DERRICK RICKY LINCOLN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1083338925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DERRICK RICKY LINCOLN

Provider Business Mailing Address
First Line	:	26463 SOLON RD
Second Line	:
City	:	BEDFORD HTS
State	:	OH
Zip	:	44146-4761
Country	:	US
Telephone Number	:	216-269-9798
Fax Number	:

Provider Business Practice Location Address
First Line	:	26463 SOLON RD APT 203
Second Line	:
City	:	BEDFORD HTS
State	:	OH
Zip	:	44146-4767
Country	:	US
Telephone Number	:	216-269-9798
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2022
Last Update Date	:	10/03/2022

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