Provider Demographics
NPI:1407523632
Name:PRESTON, RICKY DOUGLAS
Entity Type:Individual
Prefix:MR
First Name:RICKY
Middle Name:DOUGLAS
Last Name:PRESTON
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 1:26 MILL ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-1425
Mailing Address - Country:US
Mailing Address - Phone:617-866-3361
Mailing Address - Fax:
Practice Address - Street 1:3313 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2691
Practice Address - Country:US
Practice Address - Phone:617-522-0650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program