Provider Demographics
NPI:1346060506
Name:LICONA, RICARDO (RD)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:LICONA
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:RICKY
Other - Middle Name:
Other - Last Name:LICONA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD
Mailing Address - Street 1:3984 EPSILON ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92113-4222
Mailing Address - Country:US
Mailing Address - Phone:858-301-4946
Mailing Address - Fax:
Practice Address - Street 1:3984 EPSILON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-4222
Practice Address - Country:US
Practice Address - Phone:858-301-4946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty