Provider Demographics
NPI:1962696658
Name:BAUTISTA, RICKY DESI (DC)
Entity type:Individual
Prefix:MR
First Name:RICKY
Middle Name:DESI
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45-270 WILLIAM HENRY RD
Mailing Address - Street 2:STE 205
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-5808
Mailing Address - Country:US
Mailing Address - Phone:808-235-6677
Mailing Address - Fax:808-236-0844
Practice Address - Street 1:45-270 WILLIAM HENRY RD
Practice Address - Street 2:STE 205
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744-5808
Practice Address - Country:US
Practice Address - Phone:808-235-6677
Practice Address - Fax:808-236-0844
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDC420111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIF0098993OtherHMSA
HIT41117Medicare UPIN