Provider Demographics
NPI:1043424443
Name:RICO FONTILLAS INC
Entity Type:Organization
Organization Name:RICO FONTILLAS INC
Other - Org Name:RICARDO FONTILLAS MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICO
Authorized Official - Middle Name:
Authorized Official - Last Name:FONTILLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-454-0201
Mailing Address - Street 1:1090 WIGWAM PARKWAY
Mailing Address - Street 2:#100
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074
Mailing Address - Country:US
Mailing Address - Phone:702-454-0201
Mailing Address - Fax:702-454-1245
Practice Address - Street 1:1090 WIGWAM PARKWAY
Practice Address - Street 2:#100
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074
Practice Address - Country:US
Practice Address - Phone:702-454-0201
Practice Address - Fax:702-454-1245
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RICO FONTILLAS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-09
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV65012084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019612Medicaid
NV002019612Medicaid