Healthcare Provider Details

I. General information

NPI: 1740115195
Provider Name (Legal Business Name): MAXIMILLIEN DAMIEN HICKOK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 07/19/2026
Certification Date: 07/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 W 3RD ST
GROVE OK
74344-3205
US

IV. Provider business mailing address

309 W 3RD ST
GROVE OK
74344-3205
US

V. Phone/Fax

Practice location:
  • Phone: 918-787-6116
  • Fax:
Mailing address:
  • Phone: 918-787-6116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2026027417
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number209785
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: