Provider Demographics
NPI:1407276629
Name:RICKS, RICHARD DAVID (PTA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DAVID
Last Name:RICKS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36261 OKEFENOKEE DR
Mailing Address - Street 2:
Mailing Address - City:FOLKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:31537-7853
Mailing Address - Country:US
Mailing Address - Phone:912-496-7396
Mailing Address - Fax:
Practice Address - Street 1:36261 OKEFENOKEE DR
Practice Address - Street 2:
Practice Address - City:FOLKSTON
Practice Address - State:GA
Practice Address - Zip Code:31537-7853
Practice Address - Country:US
Practice Address - Phone:912-496-7396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-27
Last Update Date:2014-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA003267225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant