Provider Demographics
NPI:1821309295
Name:RICKS, BRENT CHRISTOPHER (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:CHRISTOPHER
Last Name:RICKS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 MCHENRY VILLAGE WAY STE 3
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4338
Mailing Address - Country:US
Mailing Address - Phone:209-380-2884
Mailing Address - Fax:209-526-3908
Practice Address - Street 1:1601 MCHENRY VILLAGE WAY STE 3
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4338
Practice Address - Country:US
Practice Address - Phone:209-380-2884
Practice Address - Fax:209-526-3908
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE 5055213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHH008AOtherMEDICARE PTAN