Provider Demographics
NPI:1306385455
Name:MADDOX, RYKER
Entity Type:Individual
Prefix:
First Name:RYKER
Middle Name:
Last Name:MADDOX
Suffix:
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:PO BOX 258
Mailing Address - Street 2:39 WEST MAIN STREET
Mailing Address - City:FREWSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14738-0258
Mailing Address - Country:US
Mailing Address - Phone:716-708-7908
Mailing Address - Fax:
Practice Address - Street 1:39 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREWSBURG
Practice Address - State:NY
Practice Address - Zip Code:14738-9628
Practice Address - Country:US
Practice Address - Phone:716-708-7908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY326375164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse