Healthcare Provider Details

I. General information

NPI: 1538050950
Provider Name (Legal Business Name): THOMAS MARION TICE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2025
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 4TH ST E
SOUTH POINT OH
45680-9430
US

IV. Provider business mailing address

4481 VALLEY VIEW DR
ASHLAND KY
41101-6215
US

V. Phone/Fax

Practice location:
  • Phone: 740-451-0307
  • Fax:
Mailing address:
  • Phone: 606-232-5019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: