Provider Demographics
NPI:1073176566
Name:MARAVILLA-GARCIA, RICARDO
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:MARAVILLA-GARCIA
Suffix:
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 1:522 E GRANGER AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4545
Mailing Address - Country:US
Mailing Address - Phone:209-558-4610
Mailing Address - Fax:
Practice Address - Street 1:2215 BLUE GUM AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95358-1052
Practice Address - Country:US
Practice Address - Phone:209-525-5401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist