Provider Demographics
NPI:1568922821
Name:RICO, CHARLES (ND, LAC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:RICO
Suffix:
Gender:M
Credentials:ND, LAC
Other - Prefix:DR
Other - First Name:CHARLES
Other - Middle Name:
Other - Last Name:RICO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ND, LAC
Mailing Address - Street 1:6109 39TH AVE APT L2
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-2659
Mailing Address - Country:US
Mailing Address - Phone:347-592-8225
Mailing Address - Fax:
Practice Address - Street 1:6109 39TH AVE APT L2
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-2659
Practice Address - Country:US
Practice Address - Phone:347-592-8225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006416171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist