Provider Demographics
NPI:1215383211
Name:CHANES, RICARDO ANDRES (IDC)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:ANDRES
Last Name:CHANES
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:ANDY
Other - Middle Name:RICARDO
Other - Last Name:CHANES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:IDC
Mailing Address - Street 1:3860 HAINES ST APT K
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-6362
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3860 HAINES ST APT K
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-6362
Practice Address - Country:US
Practice Address - Phone:949-933-0336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman