Provider Demographics
NPI:1609351253
Name:MERRIAM, RICKY CHARLES (LMT)
Entity Type:Individual
Prefix:MR
First Name:RICKY
Middle Name:CHARLES
Last Name:MERRIAM
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12700 HILLCREST RD
Mailing Address - Street 2:STE 125 #143
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2009
Mailing Address - Country:US
Mailing Address - Phone:469-307-1729
Mailing Address - Fax:
Practice Address - Street 1:12700 HILLCREST RD
Practice Address - Street 2:STE 125 #143
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2009
Practice Address - Country:US
Practice Address - Phone:469-307-1729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-29
Last Update Date:2018-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110566225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist