Healthcare Provider Details

I. General information

NPI: 1417764556
Provider Name (Legal Business Name): BRADLEY SETH HICKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 12/12/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 COBB AVE
MONTCALM WV
24737
US

IV. Provider business mailing address

123 COBB AVE
MONTCALM WV
24737
US

V. Phone/Fax

Practice location:
  • Phone: 304-960-2151
  • Fax:
Mailing address:
  • Phone: 304-960-2151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: