Healthcare Provider Details

I. General information

NPI: 1457799959
Provider Name (Legal Business Name): RICKY ACEVEDO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 02/12/2023
Certification Date: 02/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 N GRANITE REEF RD
SCOTTSDALE AZ
85257-3919
US

IV. Provider business mailing address

16682 N WEST POINT PKWY APT 105
SURPRISE AZ
85374-4033
US

V. Phone/Fax

Practice location:
  • Phone: 480-990-1904
  • Fax:
Mailing address:
  • Phone: 480-616-7582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number10325A
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-24845
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: