Provider Demographics
NPI:1548045735
Name:VICK SURGICAL LLC
Entity type:Organization
Organization Name:VICK SURGICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VICK
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:225-413-5637
Mailing Address - Street 1:PO BOX 80112
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70898-0112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7777 HENNESSY BLVD STE 2004
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4370
Practice Address - Country:US
Practice Address - Phone:225-769-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2568639Medicaid