Basic Information
| Provider Information | |||||||||
| NPI: | 1457343576 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SECK | ||||||||
| FirstName: | RITA | ||||||||
| MiddleName: | MARIA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRAECKEVELT | ||||||||
| OtherFirstName: | RITA | ||||||||
| OtherMiddleName: | MARIA | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 482 BULLDOG DR | ||||||||
| Address2: | |||||||||
| City: | MESQUITE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890273103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 210 N SANDHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | MESQUITE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890274789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028490558 | ||||||||
| FaxNumber: | 7023462147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 11/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | OS12604 | FL | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | DO2522 | NV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1743029 | 05 | MI | MEDICAID | 010056150 | 01 | MI | RAILROAD MEDICARE | OTHER | 5772254 | 01 | MI | AETNA | OTHER | 080B610190 | 01 | MI | BLUE CROSS | OTHER |