Provider Demographics
NPI:1396168548
Name:HICKS, RONNIE
Entity type:Individual
Prefix:
First Name:RONNIE
Middle Name:
Last Name:HICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 CENTRAL AVE SW TRLR 148
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-7681
Mailing Address - Country:US
Mailing Address - Phone:562-507-5687
Mailing Address - Fax:
Practice Address - Street 1:9600 CENTRAL AVE SW TRLR 148
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-7681
Practice Address - Country:US
Practice Address - Phone:562-507-5687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171M0000X171M00000X
NM225X0000X225X00000X
NM23550000X235500000X
NM374U0000X374U00000X
172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist
No172A00000XOther Service ProvidersDriver