Provider Demographics
NPI:1942845508
Name:DE RICCO, PHILIP FANK (LMT)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:FANK
Last Name:DE RICCO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15-2660 PAHOA VILLAGE RD
Mailing Address - Street 2:STE 203 #69
Mailing Address - City:PAHOA
Mailing Address - State:HI
Mailing Address - Zip Code:96778
Mailing Address - Country:US
Mailing Address - Phone:808-315-3447
Mailing Address - Fax:
Practice Address - Street 1:15-614 PUNI MAUKA LOOP S
Practice Address - Street 2:
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778-9415
Practice Address - Country:US
Practice Address - Phone:808-315-3447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI15944225700000X
CT8295225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist