Healthcare Provider Details

I. General information

NPI: 1063676997
Provider Name (Legal Business Name): RICCI DELORIEA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18100 WOLF TRAP CT
GORDONSVILLE VA
22942-8963
US

IV. Provider business mailing address

18100 WOLF TRAP CT
GORDONSVILLE VA
22942-8963
US

V. Phone/Fax

Practice location:
  • Phone: 434-842-2916
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306001707
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: