MEDICARE: MR. CHARLES PAUL RICKETSON OTRL

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	225X00000X	Occupational Therapist	OT 9814	FL

General Provider Information

NPI Number	:	1871662247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES PAUL RICKETSON OTRL

Provider Business Mailing Address
First Line	:	807 S PARSONS AVE
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-6063
Country	:	US
Telephone Number	:	813-684-8141
Fax Number	:	813-689-1140

Provider Business Practice Location Address
First Line	:	807 S PARSONS AVE
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-6063
Country	:	US
Telephone Number	:	813-684-8141
Fax Number	:	813-689-1140

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

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	04/15/2008

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