Healthcare Provider Details

I. General information

NPI: 1275174039
Provider Name (Legal Business Name): HICKORY HILL CONSTRUCTION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 W LEGRAND ST
BOSCOBEL WI
53805-1339
US

IV. Provider business mailing address

106 W LEGRAND ST
BOSCOBEL WI
53805-1339
US

V. Phone/Fax

Practice location:
  • Phone: 608-391-0543
  • Fax:
Mailing address:
  • Phone: 608-391-0543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State

VIII. Authorized Official

Name: TREVOR ERICKSON
Title or Position: OWNER
Credential:
Phone: 608-391-0543