Provider Demographics
NPI:1932333176
Name:RICKERT, JOSHUA R (DC)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:R
Last Name:RICKERT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16197 MAIN AVE SE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-1704
Mailing Address - Country:US
Mailing Address - Phone:952-226-5100
Mailing Address - Fax:952-516-5240
Practice Address - Street 1:16197 MAIN AVE SE
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-1704
Practice Address - Country:US
Practice Address - Phone:952-226-5100
Practice Address - Fax:952-516-5240
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-01
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5230111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350004537Medicare PIN