Provider Demographics
NPI:1326193822
Name:JACK RICCI DC PC
Entity Type:Organization
Organization Name:JACK RICCI DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:G
Authorized Official - Last Name:RICCI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:540-662-1237
Mailing Address - Street 1:111 W BOSCAWEN ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-4115
Mailing Address - Country:US
Mailing Address - Phone:540-662-8544
Mailing Address - Fax:
Practice Address - Street 1:111 W BOSCAWEN ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-4115
Practice Address - Country:US
Practice Address - Phone:540-662-8544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556410111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00X014J01Medicare ID - Type Unspecified
VAU72227Medicare UPIN