1164435202 NPI number — DR. FERDINAND REYES RICO MD

Table of content: MS. SHIRLEY J ANSTAETT MSW, LSCSW (NPI 1114023330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164435202 NPI number — DR. FERDINAND REYES RICO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RICO
Provider First Name:
FERDINAND
Provider Middle Name:
REYES
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164435202
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18310 US HIGHWAY 18
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APPLE VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92307-2206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-241-6666
Provider Business Mailing Address Fax Number:
760-947-5619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18310 US HIGHWAY 18
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APPLE VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92307-2206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-241-6666
Provider Business Practice Location Address Fax Number:
760-947-5619
Provider Enumeration Date:
08/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  N4039 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 238476 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0102X , with the licence number: N4039 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: A114111 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 210237808 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0086675 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 34383298 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200781200A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 210237807 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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