Provider Demographics
NPI:1710385612
Name:RICO, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name: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 1:17593 W POLARIS DR
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-5473
Mailing Address - Country:US
Mailing Address - Phone:602-686-3990
Mailing Address - Fax:
Practice Address - Street 1:17593 W POLARIS DR
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-5473
Practice Address - Country:US
Practice Address - Phone:602-686-3990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA762067163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA163W00000XOtherCALIFORNIA BOARD OF REGISTERED NURSES