Provider Demographics
NPI:1598742397
Name:BASTARACHE, RICKY JOHN (MSPT DPT)
Entity Type:Individual
Prefix:DR
First Name:RICKY
Middle Name:JOHN
Last Name:BASTARACHE
Suffix:
Gender:M
Credentials:MSPT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6012 LINDEN RD STE 15
Mailing Address - Street 2:
Mailing Address - City:SWARTZ CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:48473-8889
Mailing Address - Country:US
Mailing Address - Phone:810-655-8244
Mailing Address - Fax:810-655-2192
Practice Address - Street 1:6012 LINDEN RD STE 15
Practice Address - Street 2:
Practice Address - City:SWARTZ CREEK
Practice Address - State:MI
Practice Address - Zip Code:48473-8889
Practice Address - Country:US
Practice Address - Phone:810-655-8244
Practice Address - Fax:810-655-2192
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007536225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist