Healthcare Provider Details

I. General information

NPI: 1629518014
Provider Name (Legal Business Name): DAVID K. VICKERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2017
Last Update Date: 03/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 JAMES ST
ADEL GA
31620-1504
US

IV. Provider business mailing address

907 18TH ST E SUITE 150
TIFTON GA
31794-3643
US

V. Phone/Fax

Practice location:
  • Phone: 229-896-3424
  • Fax: 229-896-3838
Mailing address:
  • Phone: 229-353-3450
  • Fax: 229-353-6060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN164513
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: