Provider Demographics
NPI:1841526969
Name:RICO, VICTOR (PHD)
Entity type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:
Last Name:RICO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 VETERAN AVE
Mailing Address - Street 2:BOX 957142
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-7142
Mailing Address - Country:US
Mailing Address - Phone:310-206-2981
Mailing Address - Fax:310-794-4996
Practice Address - Street 1:1000 VETERAN AVE
Practice Address - Street 2:BOX 957142
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-7142
Practice Address - Country:US
Practice Address - Phone:310-206-2981
Practice Address - Fax:310-794-4996
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-23
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26750103TC0700X
225400000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner