MEDICARE: MARK RICKS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1235485442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK RICKS

Provider Business Mailing Address
First Line	:	1210 S GRAMERCY PL
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90019-3637
Country	:	US
Telephone Number	:	818-613-5802
Fax Number	:

Provider Business Practice Location Address
First Line	:	1210 S GRAMERCY PL
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90019-3637
Country	:	US
Telephone Number	:	818-613-5802
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2012
Last Update Date	:	07/25/2012

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Directions to “ MARK RICKS ” Practice Location

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