Provider Demographics
NPI:1144119090
Name:RICKS, JUSTIN (DPT)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:RICKS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 GOVERNOR GWINNETT WAY
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-3809
Mailing Address - Country:US
Mailing Address - Phone:229-425-5904
Mailing Address - Fax:
Practice Address - Street 1:235 SINGLETON RIDGE RD STE 102
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9136
Practice Address - Country:US
Practice Address - Phone:843-353-3460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-02
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT017906225100000X
SCCP048708T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist