Healthcare Provider Details

I. General information

NPI: 1578570792
Provider Name (Legal Business Name): KENNETH J RICCI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10745 WESTSIDE WAY STE 125
ALPHARETTA GA
30009-7635
US

IV. Provider business mailing address

10745 WESTSIDE WAY STE 125
ALPHARETTA GA
30009-7635
US

V. Phone/Fax

Practice location:
  • Phone: 770-410-4610
  • Fax: 888-990-1674
Mailing address:
  • Phone: 770-410-4610
  • Fax: 888-990-1674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number034932
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: