Healthcare Provider Details

I. General information

NPI: 1396168548
Provider Name (Legal Business Name): RONNIE HICKS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2014
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 CENTRAL AVE SW TRLR 148
ALBUQUERQUE NM
87121-7681
US

IV. Provider business mailing address

9600 CENTRAL AVE SW TRLR 148
ALBUQUERQUE NM
87121-7681
US

V. Phone/Fax

Practice location:
  • Phone: 562-507-5687
  • Fax:
Mailing address:
  • Phone: 562-507-5687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number171M0000X
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number225X0000X
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code235500000X
TaxonomySpeech/Language/Hearing Specialist/Technologist
License Number23550000X
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number374U0000X
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: