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General NPI Number Information
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NPI Number | 1699276626
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Entity Type | Individual
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Provider Name | MARIELA YESENIA RICO JIMENEZ ATC, LAT
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Gender | Female
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Dates
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Enumeration Date | 02/25/2018
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 1005 S MAIN ST
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City | FORT SCOTT
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State | KS
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Zip | 66701-2649
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Country | US
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Telephone | 620-223-0600
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Fax |
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Provider Business Mailing Address
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Address Line | 849 STATE ST APT 9
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City | FORT SCOTT
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State | KS
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Zip | 66701-2763
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Country | US
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Telephone | 580-754-0241
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 24-01137
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License Number State | KS
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