Provider Demographics
NPI:1093268492
Name:RICCA, NICHOLAS JOSEPH
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOSEPH
Last Name:RICCA
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 1:3611 SW 34TH ST APT 109
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-2593
Mailing Address - Country:US
Mailing Address - Phone:352-257-5047
Mailing Address - Fax:
Practice Address - Street 1:2620 SE MARICAMP RD
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-5582
Practice Address - Country:US
Practice Address - Phone:352-732-8868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLR200630943740390200000X
FLPT37184225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program