Provider Demographics
NPI:1821383670
Name:ROBERSON RIKE CLINIC
Entity Type:Organization
Organization Name:ROBERSON RIKE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:RIKE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:731-253-3760
Mailing Address - Street 1:768 EVERETT ST.
Mailing Address - Street 2:
Mailing Address - City:TIPTONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38079
Mailing Address - Country:US
Mailing Address - Phone:731-253-3760
Mailing Address - Fax:
Practice Address - Street 1:768 EVERETT ST.
Practice Address - Street 2:
Practice Address - City:TIPTONVILLE
Practice Address - State:TN
Practice Address - Zip Code:38079
Practice Address - Country:US
Practice Address - Phone:731-253-3760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-09
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1524187Medicaid
TN103G707688Medicare PIN