MEDICARE: HEATHER HICKSON LAC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center	AP3408	FL

General Provider Information

NPI Number	:	1407381940
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEATHER HICKSON LAC LLC

Provider Business Mailing Address
First Line	:	5353 NORTH FEDERAL HIGHWAY
Second Line	:	STE 220
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308
Country	:	US
Telephone Number	:	954-461-7529
Fax Number	:

Provider Business Practice Location Address
First Line	:	5353 NORTH FEDERAL HIGHWAY
Second Line	:	STE 220
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308
Country	:	US
Telephone Number	:	954-461-7529
Fax Number	:

Authorized Official
Title or Position	:	ACUPUNCTURIST
Name	:	HEATHER M HICKSON
Credential	:
Telephone Number	:	954-461-7529

Provider Enumeration Date	:	04/21/2017
Last Update Date	:	04/21/2017

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