Provider Demographics
NPI:1588707053
Name:HICKS CHIROPRACTIC CENTER, LLC
Entity type:Organization
Organization Name:HICKS CHIROPRACTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUBER-HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:219-879-2177
Mailing Address - Street 1:501 W. KIEFFER RD.
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-9580
Mailing Address - Country:US
Mailing Address - Phone:219-879-2177
Mailing Address - Fax:
Practice Address - Street 1:501 W. KIEFFER RD.
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9580
Practice Address - Country:US
Practice Address - Phone:219-879-2177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001435A111N00000X
IN08001324111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200431860AMedicaid
IN488870Medicare UPIN
U44245Medicare UPIN
488870BMedicare ID - Type Unspecified