Provider Demographics
NPI:1407221625
Name:BUTCHER, RICK
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:
Last Name:BUTCHER
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 1:1047 OAK ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2665
Mailing Address - Country:US
Mailing Address - Phone:530-584-6781
Mailing Address - Fax:
Practice Address - Street 1:1047 OAK ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2665
Practice Address - Country:US
Practice Address - Phone:530-584-6781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILB32672550315172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL922053087Medicaid