Provider Demographics
NPI:1942607734
Name:PERALES, RICARDO (ATC)
Entity Type:Individual
Prefix:MR
First Name:RICARDO
Middle Name:
Last Name:PERALES
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5556 W 77TH ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:IL
Mailing Address - Zip Code:60459
Mailing Address - Country:US
Mailing Address - Phone:773-892-2132
Mailing Address - Fax:
Practice Address - Street 1:5556 W 77TH ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459-1300
Practice Address - Country:US
Practice Address - Phone:773-892-2132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960036012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer