Provider Demographics
NPI:1073668265
Name:DICICCO, RICHARD W (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:W
Last Name:DICICCO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 308
Mailing Address - Street 2:1 MYERS AVE
Mailing Address - City:CEDAR BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 MYERS AVENUE
Practice Address - Street 2:
Practice Address - City:CEDAR BROOK
Practice Address - State:NJ
Practice Address - Zip Code:08018
Practice Address - Country:US
Practice Address - Phone:609-561-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00418400111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0673372000OtherAMERIHEALTH
NJ2230846OtherAETNA
NJ0673372000OtherAMERIHEALTH