=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770668691
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HICKMAN CHIROPRACTIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 04/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 EAST LAKESHORE DRIVE
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-682-5656
-----------------------------------------------------
Fax | 715-682-5225
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 EAST LAKESHORE DRIVE
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-682-5656
-----------------------------------------------------
Fax | 715-682-5225
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PATRICK ALAN HICKMAN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 715-682-5656
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2542
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------