Provider Demographics
NPI:1295877637
Name:CALLICOAT, RICKE DALE
Entity type:Individual
Prefix:
First Name:RICKE
Middle Name:DALE
Last Name:CALLICOAT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24789 WILDLIFE DR
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:MO
Mailing Address - Zip Code:65355-3751
Mailing Address - Country:US
Mailing Address - Phone:816-956-1640
Mailing Address - Fax:
Practice Address - Street 1:2133 NW 13TH ST
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015-7734
Practice Address - Country:US
Practice Address - Phone:816-224-0003
Practice Address - Fax:816-224-2199
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant