Healthcare Provider Details

I. General information

NPI: 1376941641
Provider Name (Legal Business Name): CALLIE HICKS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2014
Last Update Date: 12/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 PARADISE DR
WEST BEND WI
53095-9000
US

IV. Provider business mailing address

1700 PARADISE DR
WEST BEND WI
53095-9000
US

V. Phone/Fax

Practice location:
  • Phone: 262-334-3451
  • Fax:
Mailing address:
  • Phone: 262-334-3451
  • Fax: 262-334-0041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2742
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: