Provider Demographics
NPI:1326655374
Name:REYNAGA ROMERO, RICO
Entity Type:Individual
Prefix:
First Name:RICO
Middle Name:
Last Name:REYNAGA ROMERO
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 1:121 BETHEL AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-5149
Mailing Address - Country:US
Mailing Address - Phone:505-355-9016
Mailing Address - Fax:
Practice Address - Street 1:121 BETHEL AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-5149
Practice Address - Country:US
Practice Address - Phone:505-355-9016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician