Healthcare Provider Details

I. General information

NPI: 1326729534
Provider Name (Legal Business Name): MIRIAM RICSI-PEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 07/31/2023
Certification Date: 07/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2046 JONATHAN CREEK RD
ARTHUR IL
61911-6108
US

IV. Provider business mailing address

104 STERLING CT APT 304
SAVOY IL
61874-8012
US

V. Phone/Fax

Practice location:
  • Phone: 217-962-0614
  • Fax:
Mailing address:
  • Phone: 217-328-7034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227022986
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: