1225414535 NPI number — MIKE P RICKE LAT

Table of content: MR. ISAAC BORRERO PAGAN SR. RN (NPI 1962383174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225414535 NPI number — MIKE P RICKE LAT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RICKE
Provider First Name:
MIKE
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LAT
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:
1225414535
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1228 TAMU ST
Provider Second Line Business Mailing Address:
TEXAS A&M ATHLETIC DEPT. REED ARENA
Provider Business Mailing Address City Name:
COLLEGE STATION
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77843-1228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-845-9513
Provider Business Mailing Address Fax Number:
979-862-1791

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1228 TAMU ST
Provider Second Line Business Practice Location Address:
TEXAS A&M ATHLETIC DEPT. REED ARENA
Provider Business Practice Location Address City Name:
COLLEGE STATION
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77843-1228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-845-9513
Provider Business Practice Location Address Fax Number:
979-862-1791
Provider Enumeration Date:
08/10/2015

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: 390200000X , with the licence number:  700 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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