Basic Information
| Provider Information | |||||||||
| NPI: | 1194211912 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICO | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10851 MOORPARK ST APT 7 | ||||||||
| Address2: | |||||||||
| City: | NORTH HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 916023924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109240783 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4940 VAN NUYS BLVD STE 301 | ||||||||
| Address2: | |||||||||
| City: | SHERMAN OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914031742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189070952 | ||||||||
| FaxNumber: | 8189909449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2018 | ||||||||
| LastUpdateDate: | 07/04/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 10527 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.