Healthcare Provider Details

I. General information

NPI: 1922748276
Provider Name (Legal Business Name): BETTY HICKS LRD RN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 BLANDINA CT
FORT MILL SC
29708-6433
US

IV. Provider business mailing address

130 BLANDINA CT
FORT MILL SC
29708-6433
US

V. Phone/Fax

Practice location:
  • Phone: 803-448-7894
  • Fax: 803-961-6757
Mailing address:
  • Phone: 803-448-7894
  • Fax: 803-961-6757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: BETTY HICKS
Title or Position: OWNER/PROVIDER
Credential: LRD,RN
Phone: 803-448-7894