Healthcare Provider Details

I. General information

NPI: 1861973992
Provider Name (Legal Business Name): FAITH MADERAH HICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 E FOOTHILL BLVD
PASADENA CA
91107-3439
US

IV. Provider business mailing address

6272 JASMINE DR
HUNTINGTON BEACH CA
92648-6712
US

V. Phone/Fax

Practice location:
  • Phone: 626-577-2261
  • Fax:
Mailing address:
  • Phone: 714-318-5873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: