Provider Demographics
NPI:1790147908
Name:RICHARD WA RICKMAN LLC
Entity Type:Organization
Organization Name:RICHARD WA RICKMAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:RICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-469-7729
Mailing Address - Street 1:2804 N OAK ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-5914
Mailing Address - Country:US
Mailing Address - Phone:229-469-7730
Mailing Address - Fax:229-469-7729
Practice Address - Street 1:2804 N OAK ST
Practice Address - Street 2:SUITE A
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-5914
Practice Address - Country:US
Practice Address - Phone:229-469-7730
Practice Address - Fax:229-469-7729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-26
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049332305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization