Provider Demographics
NPI:1265831630
Name:RICO, VICTOR SR
Entity Type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:
Last Name:RICO
Suffix:SR
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 1:9419 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:WONDER LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60097-7549
Mailing Address - Country:US
Mailing Address - Phone:815-527-2999
Mailing Address - Fax:
Practice Address - Street 1:10 N VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-4139
Practice Address - Country:US
Practice Address - Phone:815-459-3860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227012244174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist