Provider Demographics
NPI:1720673619
Name:WICKS, ROAMON
Entity type:Individual
Prefix:
First Name:ROAMON
Middle Name:
Last Name:WICKS
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 1:5910 W HALEH AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-8788
Mailing Address - Country:US
Mailing Address - Phone:520-389-3769
Mailing Address - Fax:
Practice Address - Street 1:3085 S JONES BLVD STE D
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-6767
Practice Address - Country:US
Practice Address - Phone:702-888-0036
Practice Address - Fax:702-888-0035
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner