Provider Demographics
NPI:1255106027
Name:VALLEJOS, RICO EMILIO (PTA)
Entity type:Individual
Prefix:
First Name:RICO
Middle Name:EMILIO
Last Name:VALLEJOS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 BRIDGER LN
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5410
Mailing Address - Country:US
Mailing Address - Phone:719-640-9778
Mailing Address - Fax:
Practice Address - Street 1:615 BRIDGER LN
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5410
Practice Address - Country:US
Practice Address - Phone:719-640-9778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0015173225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant