Provider Demographics
NPI:1558033621
Name:HICKS, BRENTON DESHAWN (DC)
Entity type:Individual
Prefix:DR
First Name:BRENTON
Middle Name:DESHAWN
Last Name:HICKS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5563 NW BARRY RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64154-1408
Mailing Address - Country:US
Mailing Address - Phone:816-710-6673
Mailing Address - Fax:816-710-6673
Practice Address - Street 1:5563 NW BARRY RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64154-1408
Practice Address - Country:US
Practice Address - Phone:816-710-6673
Practice Address - Fax:816-710-6673
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021018729111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor