Provider Demographics
NPI:1316324767
Name:RICKS, ROSE
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:RICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2816 ASPEN GROVE CT NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24017-3160
Mailing Address - Country:US
Mailing Address - Phone:540-330-2914
Mailing Address - Fax:
Practice Address - Street 1:2816 ASPEN GROVE CT NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-3160
Practice Address - Country:US
Practice Address - Phone:540-330-2914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA122772332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition