1285258368 NPI number — TICE RIDLEY

Table of content: TICE RIDLEY (NPI 1285258368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285258368 NPI number — TICE RIDLEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIDLEY
Provider First Name:
TICE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285258368
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 406
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAY PINES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33744-0406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-410-3774
Provider Business Mailing Address Fax Number:
727-499-7526

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19717 BOWER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DADE CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33523-6867
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-859-9006
Provider Business Practice Location Address Fax Number:
727-499-7526
Provider Enumeration Date:
06/03/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)