MEDICARE: 1 STIKK MOBILE RICHMOND

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QH0100X	Health Service Clinic/Center
2	261QU0200X	Urgent Care Clinic/Center
3	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1821781063
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1 STIKK MOBILE RICHMOND

Provider Business Mailing Address
First Line	:	1121 STAINBACK ST
Second Line	:	APT 3201
City	:	PETERSBURG
State	:	VA
Zip	:	23803-3969
Country	:	US
Telephone Number	:	318-512-0170
Fax Number	:

Provider Business Practice Location Address
First Line	:	1121 STAINBACK ST
Second Line	:	APT 3201
City	:	PETERSBURG
State	:	VA
Zip	:	23803-3969
Country	:	US
Telephone Number	:	318-512-0170
Fax Number	:

Authorized Official
Title or Position	:	OWNERR
Name	:	TIFFANY CLINTON
Credential	:	CPT.RMA
Telephone Number	:	318-512-0170

Provider Enumeration Date	:	06/01/2023
Last Update Date	:	12/22/2024

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