Provider Demographics
NPI:1629761812
Name:HICKS, RYAN CARLTON GREGORY
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:CARLTON GREGORY
Last Name:HICKS
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 1:6235 RIVER CREST DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-0788
Mailing Address - Country:US
Mailing Address - Phone:951-653-7561
Mailing Address - Fax:
Practice Address - Street 1:6235 RIVER CREST DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0788
Practice Address - Country:US
Practice Address - Phone:951-653-7561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-01
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator