Provider Demographics
NPI:1851692891
Name:DDMR PLLC
Entity Type:Organization
Organization Name:DDMR PLLC
Other - Org Name:HEALTH SOURCE OF MONROE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORGANIZING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RICCOBONI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:336-766-5935
Mailing Address - Street 1:420 UTILITY DR
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8397
Mailing Address - Country:US
Mailing Address - Phone:336-766-5935
Mailing Address - Fax:336-766-5365
Practice Address - Street 1:1309 E SUNSET DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-4324
Practice Address - Country:US
Practice Address - Phone:704-296-9090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3062261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890833WMedicaid
NC085HMMedicaid
NC1477587947OtherNPI
NC1013998848OtherNPI
NC085HMMedicaid
NC2456520Medicare PIN
NC890833WMedicaid
NC2450746AMedicare PIN