Provider Demographics
NPI:1548716814
Name:VICK, CHRISTOPHER (LAT, ATC, CSCS)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:VICK
Suffix:
Gender:M
Credentials:LAT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4632 COLFAX AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419
Mailing Address - Country:US
Mailing Address - Phone:612-296-6588
Mailing Address - Fax:
Practice Address - Street 1:2125 N LAKE AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805
Practice Address - Country:US
Practice Address - Phone:612-296-6588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22592255A2300X
CT10232255A2300X
FLAL38042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer