=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093083768
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RENALYN RICO RPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2011
-----------------------------------------------------
Last Update Date | 12/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | GEM STAFFING INC, 5440 N. CUMBERLAND 101A
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-436-2230
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | GEM STAFFING INC, 5440 N. CUMBERLAND 101A
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 070018436
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------