Provider Demographics
NPI:1053511345
Name:MELINDA L HICKS, O.D., P.C.
Entity Type:Organization
Organization Name:MELINDA L HICKS, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MILHOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-243-9681
Mailing Address - Street 1:2737 CROSSROADS BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-3954
Mailing Address - Country:US
Mailing Address - Phone:970-243-9681
Mailing Address - Fax:970-243-9155
Practice Address - Street 1:2737 CROSSROADS BLVD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-3954
Practice Address - Country:US
Practice Address - Phone:970-243-9681
Practice Address - Fax:970-243-9155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1453152W00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO52436861Medicaid
COC450118Medicare PIN
CO52436861Medicaid