Provider Demographics
NPI:1457749939
Name:BRENT RICKS DPM
Entity Type:Organization
Organization Name:BRENT RICKS DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CHAIRMAN OF THE BOARD
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:C
Authorized Official - Last Name:RICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:209-380-7760
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:209-380-7760
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:209-380-7760
Practice Address - Fax:209-526-3908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5055213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty