Provider Demographics
NPI:1225414535
Name:RICKE, MIKE P (LAT)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:P
Last Name:RICKE
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1228 TAMU ST
Mailing Address - Street 2:TEXAS A&M ATHLETIC DEPT. REED ARENA
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77843-1228
Mailing Address - Country:US
Mailing Address - Phone:979-845-9513
Mailing Address - Fax:979-862-1791
Practice Address - Street 1:1228 TAMU ST
Practice Address - Street 2:TEXAS A&M ATHLETIC DEPT. REED ARENA
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77843-1228
Practice Address - Country:US
Practice Address - Phone:979-845-9513
Practice Address - Fax:979-862-1791
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX700390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program