Provider Demographics
NPI:1871555169
Name:IMPASTATO, RICCO V (DC)
Entity type:Individual
Prefix:
First Name:RICCO
Middle Name:V
Last Name:IMPASTATO
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 1:3440 DIVISION ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002
Mailing Address - Country:US
Mailing Address - Phone:504-456-8560
Mailing Address - Fax:504-456-8562
Practice Address - Street 1:826 FOCIS ST
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70005-2200
Practice Address - Country:US
Practice Address - Phone:504-456-8560
Practice Address - Fax:504-456-8562
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1377111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
V05902Medicare UPIN
4H544Medicare ID - Type Unspecified