Provider Demographics
NPI:1720498538
Name:DICICCO, MICHAEL (BOCP, BEBOCO, CPED)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DICICCO
Suffix:
Gender:M
Credentials:BOCP, BEBOCO, CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 HAMILTON ST
Mailing Address - Street 2:STE D
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-2746
Mailing Address - Country:US
Mailing Address - Phone:252-535-0077
Mailing Address - Fax:252-535-0078
Practice Address - Street 1:725 HAMILTON ST
Practice Address - Street 2:STE D
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-2746
Practice Address - Country:US
Practice Address - Phone:252-535-0077
Practice Address - Fax:252-535-0078
Is Sole Proprietor?:No
Enumeration Date:2014-05-01
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist