Provider Demographics
NPI:1679925176
Name:HARRIS, RICKEY
Entity Type:Individual
Prefix:
First Name:RICKEY
Middle Name:
Last Name:HARRIS
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 1:2789 JEFFERSON ST APT 702
Mailing Address - Street 2:
Mailing Address - City:ROCK CREEK
Mailing Address - State:OH
Mailing Address - Zip Code:44084-8603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2789 JEFFERSON ST APT 702
Practice Address - Street 2:
Practice Address - City:ROCK CREEK
Practice Address - State:OH
Practice Address - Zip Code:44084-8603
Practice Address - Country:US
Practice Address - Phone:440-969-5440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSU063048172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver