Provider Demographics
NPI:1073913430
Name:DE LA O, RICARDO ANTONIO (LMT)
Entity Type:Individual
Prefix:MR
First Name:RICARDO
Middle Name:ANTONIO
Last Name:DE LA O
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 CHAPARRAL ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-5701
Mailing Address - Country:US
Mailing Address - Phone:575-386-2202
Mailing Address - Fax:
Practice Address - Street 1:2505 CHAPARRAL ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-5701
Practice Address - Country:US
Practice Address - Phone:575-386-2202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7645225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist