Basic Information
| Provider Information | |||||||||
| NPI: | 1598472797 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERTICH | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | JEFFREY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12070 TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | SANTA FE SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906703771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5627777500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11015 BLOOMFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA FE SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906704601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629062685 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2022 | ||||||||
| LastUpdateDate: | 10/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146N00000X | E110670 | CA | Y | Emergency Medical Service Providers | Emergency Medical Technician, Basic |
No ID Information.