MEDICARE: RICKI TUFFENTSAMER PTA

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	225200000X	Physical Therapy Assistant	160005048	IL
2	225200000X	Physical Therapy Assistant	2100573	TX
3	225200000X	Physical Therapy Assistant	A-1344	NM

General Provider Information

NPI Number	:	1659898252
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICKI TUFFENTSAMER PTA

Provider Business Mailing Address
First Line	:	406 RADISSON RD
Second Line	:
City	:	MARQUETTE HEIGHTS
State	:	IL
Zip	:	61554-1454
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	406 RADISSON RD
Second Line	:
City	:	MARQUETTE HEIGHTS
State	:	IL
Zip	:	61554-1454
Country	:	US
Telephone Number	:	309-472-6541
Fax Number	:

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

Provider Enumeration Date	:	08/24/2017
Last Update Date	:	08/24/2017

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Directions to “ RICKI TUFFENTSAMER PTA” Practice Location

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