Provider Demographics
NPI:1235111287
Name:HICKS, KENNETH LEE JR (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEE
Last Name:HICKS
Suffix:JR
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 1:610 OLD TAR VILLAGE RD STE E
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-7936
Mailing Address - Country:US
Mailing Address - Phone:252-215-0990
Mailing Address - Fax:252-215-0922
Practice Address - Street 1:610 OLD TAR VILLAGE RD STE E
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-7936
Practice Address - Country:US
Practice Address - Phone:252-215-0990
Practice Address - Fax:252-215-0922
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2728111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890839UMedicaid
NC890839UMedicaid