Provider Demographics
NPI:1013998848
Name:RICCOBONI, MICHAEL JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:RICCOBONI
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 1:6774 RIVER CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8999
Mailing Address - Country:US
Mailing Address - Phone:336-766-5935
Mailing Address - Fax:336-766-5365
Practice Address - Street 1:6774 RIVER CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8999
Practice Address - Country:US
Practice Address - Phone:336-766-5935
Practice Address - Fax:336-766-5365
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3062111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
648441OtherACN PROVIDER NUMBER
41-2094316OtherALL OTHER NETWORKS
NC085HMOtherBLUECROSS/BLUE SHIELD NUM
NC89085HMMedicaid
NC085HMOtherBLUECROSS/BLUE SHIELD NUM
2456520Medicare ID - Type UnspecifiedINDIVIDUAL # TO CLINIC
NC89085HMMedicaid