Healthcare Provider Details

I. General information

NPI: 1568595304
Provider Name (Legal Business Name): T JEFFERSON HICKS OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9340 HELENA RD SUITE F, #314
BIRMINGHAM AL
35244-1794
US

IV. Provider business mailing address

PO BOX 7396
ROCKY MOUNT NC
27804-0396
US

V. Phone/Fax

Practice location:
  • Phone: 252-985-1371
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS340TA047
License Number StateAL

VIII. Authorized Official

Name: THOMAS HICKS
Title or Position: OPTOMETRIST
Credential: OD
Phone: 252-985-1371