Provider Demographics
NPI:1427252840
Name:RICKETT, MATTHEW L (DOM)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
Last Name:RICKETT
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1152 EULA ST
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-3108
Mailing Address - Country:US
Mailing Address - Phone:850-934-4194
Mailing Address - Fax:
Practice Address - Street 1:1796 NAVARRE BY THE SOUND CIR
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-5103
Practice Address - Country:US
Practice Address - Phone:850-936-8664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2386171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist