Provider Demographics
NPI:1225796238
Name:GRIFFIN, RICKEY M JR
Entity Type:Individual
Prefix:
First Name:RICKEY
Middle Name:M
Last Name:GRIFFIN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10626 RIDGELAND AVE APT 3B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-1895
Mailing Address - Country:US
Mailing Address - Phone:708-737-6846
Mailing Address - Fax:
Practice Address - Street 1:12800 N LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-2418
Practice Address - Country:US
Practice Address - Phone:708-737-6846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer