Provider Demographics
NPI:1932671062
Name:MAK, RICKY WAIKEI (OTR, L)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:WAIKEI
Last Name:MAK
Suffix:
Gender:M
Credentials:OTR, L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1587 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-1453
Mailing Address - Country:US
Mailing Address - Phone:707-441-1931
Mailing Address - Fax:707-441-1940
Practice Address - Street 1:1587 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1453
Practice Address - Country:US
Practice Address - Phone:707-441-1931
Practice Address - Fax:707-441-1940
Is Sole Proprietor?:No
Enumeration Date:2018-12-31
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT15812225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist