Provider Demographics
NPI:1366117632
Name:SHOWMAN, RICKY DALE JR
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:DALE
Last Name:SHOWMAN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 TUCKER HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:FALL BRANCH
Mailing Address - State:TN
Mailing Address - Zip Code:37656-2040
Mailing Address - Country:US
Mailing Address - Phone:423-292-0251
Mailing Address - Fax:
Practice Address - Street 1:2830 HIGHWAY 394
Practice Address - Street 2:
Practice Address - City:BLOUNTVILLE
Practice Address - State:TN
Practice Address - Zip Code:37617-5577
Practice Address - Country:US
Practice Address - Phone:423-274-6191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3617224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant