Provider Demographics
NPI:1407949134
Name:MCKIBBEN, RICHARD J (PT, DWC, ECS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:MCKIBBEN
Suffix:
Gender:M
Credentials:PT, DWC, ECS
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 949
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0949
Mailing Address - Country:US
Mailing Address - Phone:706-236-2774
Mailing Address - Fax:706-802-1408
Practice Address - Street 1:100 A LINDSEY LANE
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-0000
Practice Address - Country:US
Practice Address - Phone:912-729-1333
Practice Address - Fax:912-729-5259
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT004832225100000X, 2251E1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, Clinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA818354932JMedicaid