Provider Demographics
NPI:1417724758
Name:GARCIA RICO, JERRY ANGEL
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:ANGEL
Last Name:GARCIA RICO
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 1:5825 W 25TH CT APT 308
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-4468
Mailing Address - Country:US
Mailing Address - Phone:786-930-2632
Mailing Address - Fax:
Practice Address - Street 1:7955 NW 12TH ST STE 405
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1823
Practice Address - Country:US
Practice Address - Phone:786-615-4409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-06
Last Update Date:2023-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLG626421980090106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician