1760424113 NPI number — HICKOK REHABILITATION SERVICES, LLC

Table of content: (NPI 1760424113)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760424113 NPI number — HICKOK REHABILITATION SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HICKOK REHABILITATION SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DUNAMIS THERAPY & FITNESS
Provider Other Organization Name Type Code:
3
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:
1760424113
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 418
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54722
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-286-2203
Provider Business Mailing Address Fax Number:
715-286-2076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
836 RICHARD DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
EAU CLAIRE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54701-6242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-834-5850
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HICKOK
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER/ PHYSICAL THERAPIST
Authorized Official Telephone Number:
715-286-2203

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  4639-02 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 601601600 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 7397 . This is a "GROUP HEALTH" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 000081145 . This is a "MEDICARE PTAN FOR THORP & CHETEK" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 68848 . This is a "SECURITY HEALTH PLAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 533689001 . This is a "DME MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 7398 . This is a "GROUP HEALTH" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 40253000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5336890002 . This is a "DME PROVIDER #" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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