Provider Demographics
NPI:1982700456
Name:PETHERS, RICKY LYNN (DC)
Entity type:Individual
Prefix:DR
First Name:RICKY
Middle Name:LYNN
Last Name:PETHERS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 BOYNE AVE
Mailing Address - Street 2:
Mailing Address - City:BOYNE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49712-1263
Mailing Address - Country:US
Mailing Address - Phone:231-582-6581
Mailing Address - Fax:231-582-6449
Practice Address - Street 1:430 BOYNE AVE
Practice Address - Street 2:
Practice Address - City:BOYNE CITY
Practice Address - State:MI
Practice Address - Zip Code:49712-1263
Practice Address - Country:US
Practice Address - Phone:231-582-6581
Practice Address - Fax:231-582-6449
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301002936111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2099227Medicaid
MI950A55010OtherBLUE CROSS/BLUE SHIELD
MI2099227Medicaid