Healthcare Provider Details

I. General information

NPI: 1063261261
Provider Name (Legal Business Name): ERIN HICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2024
Last Update Date: 05/18/2024
Certification Date: 05/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 LEGGETT RD
DALLAS GA
30157-6151
US

IV. Provider business mailing address

277 LEGGETT RD
DALLAS GA
30157-6151
US

V. Phone/Fax

Practice location:
  • Phone: 404-452-8416
  • Fax:
Mailing address:
  • Phone: 404-452-8416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberMT006620
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberMT006620
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT006620
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: