MEDICARE: DR. RICKY JOHN BASTARACHE MSPT DPT

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	225100000X	Physical Therapist	5501007536	MI

General Provider Information

NPI Number	:	1598742397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICKY JOHN BASTARACHE MSPT DPT

Provider Business Mailing Address
First Line	:	6012 LINDEN RD STE 15
Second Line	:
City	:	SWARTZ CREEK
State	:	MI
Zip	:	48473-8889
Country	:	US
Telephone Number	:	810-655-8244
Fax Number	:	810-655-2192

Provider Business Practice Location Address
First Line	:	6012 LINDEN RD STE 15
Second Line	:
City	:	SWARTZ CREEK
State	:	MI
Zip	:	48473-8889
Country	:	US
Telephone Number	:	810-655-8244
Fax Number	:	810-655-2192

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

Provider Enumeration Date	:	12/22/2005
Last Update Date	:	10/16/2020

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