MEDICARE: KOBE BERNARD HICKS

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	2255A2300X	Athletic Trainer		IN
2	390200000X	Student in an Organized Health Care Education/Training Program		IN

General Provider Information

NPI Number	:	1447112313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KOBE BERNARD HICKS

Provider Business Mailing Address
First Line	:	3008 PARNELL AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-2551
Country	:	US
Telephone Number	:	770-500-6068
Fax Number	:

Provider Business Practice Location Address
First Line	:	3008 PARNELL AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-2551
Country	:	US
Telephone Number	:	770-500-6068
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2025
Last Update Date	:	12/01/2025

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Directions to “ KOBE BERNARD HICKS ” Practice Location

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