Provider Demographics
NPI:1225411648
Name:RYCKEBOSCH, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:RYCKEBOSCH
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 1:425 CAMINO DE GRATO
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89441-7536
Mailing Address - Country:US
Mailing Address - Phone:775-848-4302
Mailing Address - Fax:
Practice Address - Street 1:425 CAMINO DE GRATO
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89441-7536
Practice Address - Country:US
Practice Address - Phone:775-848-4302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV14Medicaid