Healthcare Provider Details

I. General information

NPI: 1760982128
Provider Name (Legal Business Name): CHAD R HICKERSON MAOD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 SOQUEL AVE
SANTA CRUZ CA
95062-1402
US

IV. Provider business mailing address

2250 SOQUEL AVE
SANTA CRUZ CA
95062-1402
US

V. Phone/Fax

Practice location:
  • Phone: 831-600-2801
  • Fax: 831-600-2801
Mailing address:
  • Phone: 831-600-2801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: