1629057203 NPI number — DR. HEATHER L HICKSON O.D.

Table of content: DR. HEATHER L HICKSON O.D. (NPI 1629057203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629057203 NPI number — DR. HEATHER L HICKSON O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HICKSON
Provider First Name:
HEATHER
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629057203
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1195
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARDEN
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28704-1195
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-687-7500
Provider Business Mailing Address Fax Number:
828-687-7333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 AIRPORT RD
Provider Second Line Business Practice Location Address:
SUITE L
Provider Business Practice Location Address City Name:
ARDEN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28704-8599
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-687-7500
Provider Business Practice Location Address Fax Number:
828-687-7333
Provider Enumeration Date:
01/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1812 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 89093G9 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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