Provider Demographics
NPI:1154085975
Name:AGUDELO, LUIS RICO (LMT)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:RICO
Last Name:AGUDELO
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 1:7686 BOUNDARY AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-1268
Mailing Address - Country:US
Mailing Address - Phone:407-454-4766
Mailing Address - Fax:
Practice Address - Street 1:2606 SPENARD RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2309
Practice Address - Country:US
Practice Address - Phone:907-279-7669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK175970225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist