Provider Demographics
NPI:1699276626
Name:RICO JIMENEZ, MARIELA YESENIA (ATC, LAT)
Entity type:Individual
Prefix:MS
First Name:MARIELA
Middle Name:YESENIA
Last Name:RICO JIMENEZ
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:849 STATE ST APT 9
Mailing Address - Street 2:
Mailing Address - City:FORT SCOTT
Mailing Address - State:KS
Mailing Address - Zip Code:66701-2763
Mailing Address - Country:US
Mailing Address - Phone:580-754-0241
Mailing Address - Fax:
Practice Address - Street 1:1005 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT SCOTT
Practice Address - State:KS
Practice Address - Zip Code:66701-2649
Practice Address - Country:US
Practice Address - Phone:620-223-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-011372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer