Provider Demographics
NPI:1346008034
Name:RICO CHACON, BRIAN
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:RICO CHACON
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 1:9214B SAN MIGUEL AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-4812
Mailing Address - Country:US
Mailing Address - Phone:323-314-2578
Mailing Address - Fax:
Practice Address - Street 1:1515 W 190TH ST STE 300
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4925
Practice Address - Country:US
Practice Address - Phone:310-329-9115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician