Provider Demographics
NPI:1770760530
Name:LICTO, ALVARO (RD)
Entity type:Individual
Prefix:
First Name:ALVARO
Middle Name:
Last Name:LICTO
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47923 OASIS ST
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-9788
Mailing Address - Country:US
Mailing Address - Phone:760-863-8268
Mailing Address - Fax:
Practice Address - Street 1:47923 OASIS ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-9788
Practice Address - Country:US
Practice Address - Phone:760-863-8268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA954507133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered