1710906490 NPI number — MR. RICKY T BURRESCIA P.A.-C

Table of content: MR. RICKY T BURRESCIA P.A.-C (NPI 1710906490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710906490 NPI number — MR. RICKY T BURRESCIA P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURRESCIA
Provider First Name:
RICKY
Provider Middle Name:
T
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C
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:
1710906490
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4002 21ST ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79410-1135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-793-1406
Provider Business Mailing Address Fax Number:
806-796-1167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4002 21ST ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79410-1135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-793-1406
Provider Business Practice Location Address Fax Number:
806-796-1167
Provider Enumeration Date:
07/19/2006

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: 363A00000X , with the licence number:  PA00664 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1008402 . This is a "NCCPA CERTIFICATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: PA00664 . This is a "STATE LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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