Provider Demographics
NPI:1326526245
Name:CUZZORT, RICKEY
Entity Type:Individual
Prefix:
First Name:RICKEY
Middle Name:
Last Name:CUZZORT
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 1:535 COUNTY ROAD 420
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:TX
Mailing Address - Zip Code:76574-3948
Mailing Address - Country:US
Mailing Address - Phone:512-484-3474
Mailing Address - Fax:
Practice Address - Street 1:109 HOMESTEAD DR
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-2396
Practice Address - Country:US
Practice Address - Phone:512-689-1511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX160577164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse