Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0400X | Rehabilitation Chiropractor | 08001324A | IN |
NPI | 1073656534 |
---|---|
Provider Name | Dr. Brent Hicks |
First Address | Michigan City, IN 46360-9580 |
Second Address | Michigan City, IN 46360-9580 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/02/2007 |
Last Update Date | 30/09/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200431860A | (05) | IN |
U26421 | (02) | IN |