Healthcare Provider Details

I. General information

NPI: 1114315140
Provider Name (Legal Business Name): BENJAMIN HICKS MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2014
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 EMERSON RD SUITE 20
CREVE COEUR MO
63141-6739
US

IV. Provider business mailing address

633 EMERSON RD SUITE 20
CREVE COEUR MO
63141-6739
US

V. Phone/Fax

Practice location:
  • Phone: 314-325-3068
  • Fax: 314-325-3069
Mailing address:
  • Phone: 314-325-3068
  • Fax: 314-325-3069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2014028850
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: