Healthcare Provider Details

I. General information

NPI: 1730610601
Provider Name (Legal Business Name): DALLAS WHICKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 AMNICOLA HWY
CHATTANOOGA TN
37406-3603
US

IV. Provider business mailing address

2710 AMNICOLA HWY
CHATTANOOGA TN
37406-3603
US

V. Phone/Fax

Practice location:
  • Phone: 423-698-8971
  • Fax: 423-624-5160
Mailing address:
  • Phone: 423-698-8971
  • Fax: 423-624-5160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberPRO0000000032
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: