Healthcare Provider Details

I. General information

NPI: 1821861345
Provider Name (Legal Business Name): MR. DWAYNE EVERETT HICKS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1078 LAKE ROYALE 129 CHOCTAW DRIVE
LOUISBURG NC
27549
US

IV. Provider business mailing address

1078 LAKE ROYALE 129 CHOCTAW DRIVE
LOUISBURG NC
27549
US

V. Phone/Fax

Practice location:
  • Phone: 252-425-7746
  • Fax:
Mailing address:
  • Phone: 252-425-7746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: