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General NPI Number Information
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NPI Number | 1467011148
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Entity Type | Individual
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Provider Name | GEORGE LEMAR HICKS III ATC
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Gender | Male
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Dates
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Enumeration Date | 06/06/2019
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Last Update Date | 06/06/2019
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Provider Practice Location Address
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Address Line | 4360 SETTLEMENT WAY
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City | COLORADO SPRINGS
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State | CO
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Zip | 80925-9597
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Country | US
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Telephone | 260-636-0847
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Fax |
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Provider Business Mailing Address
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Address Line | 4360 SETTLEMENT WAY
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City | COLORADO SPRINGS
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State | CO
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Zip | 80925-9597
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Country | US
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Telephone | 260-636-0847
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207PS0010X
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Taxonomy Name | Sports Medicine (Emergency Medicine) Physician
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License Number | AT.0001695
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License Number State | CO
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