Healthcare Provider Details

I. General information

NPI: 1649664376
Provider Name (Legal Business Name): MARQUELL RICKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2015
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9890 COUNTY FARM RD STE 1
RIVERSIDE CA
92503-3678
US

IV. Provider business mailing address

615 W CIVIC CENTER DR STE 200
SANTA ANA CA
92701-4052
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-8339
  • Fax: 951-715-5041
Mailing address:
  • Phone: 714-795-3444
  • Fax: 714-795-3443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number1649664376
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: