Healthcare Provider Details

I. General information

NPI: 1679180087
Provider Name (Legal Business Name): REBECCA HICKLIN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 PATRIOT LN
EDGEMOOR SC
29712-8704
US

IV. Provider business mailing address

531 PATRIOT LN
EDGEMOOR SC
29712-8704
US

V. Phone/Fax

Practice location:
  • Phone: 864-350-8885
  • Fax: 964-794-3578
Mailing address:
  • Phone: 864-350-8885
  • Fax: 864-794-3578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1961
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: