=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720553738
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MILDRED V KICK LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2018
-----------------------------------------------------
Last Update Date | 10/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 213 N BLACK RIVER ST
-----------------------------------------------------
City | SPARTA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54656-1529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-487-9990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | MILLIE KICK N2610 ANTONY RD
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54614-9315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-486-2927
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 755-146
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------