Healthcare Provider Details

I. General information

NPI: 1821060419
Provider Name (Legal Business Name): KEVIN W. HICKS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 EUREKA TOWNE CENTER DR
EUREKA MO
63025-1031
US

IV. Provider business mailing address

131 EUREKA TOWNE CENTER DR
EUREKA MO
63025-1031
US

V. Phone/Fax

Practice location:
  • Phone: 636-587-9775
  • Fax: 636-587-9796
Mailing address:
  • Phone: 636-587-9775
  • Fax: 636-587-9796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02874
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: