Healthcare Provider Details

I. General information

NPI: 1295836757
Provider Name (Legal Business Name): MARK HICKS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280 W LAMBERT RD SUITE B
BREA CA
92821-2820
US

IV. Provider business mailing address

1280 W LAMBERT RD SUITE B
BREA CA
92821-2820
US

V. Phone/Fax

Practice location:
  • Phone: 562-691-7161
  • Fax: 562-691-7162
Mailing address:
  • Phone: 562-691-7161
  • Fax: 562-691-7162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number10079550
License Number StateCA

VIII. Authorized Official

Name: MR. MARK P HICKS
Title or Position: PRESIDENT
Credential: BS RRT RCP
Phone: 562-691-7161