Provider Demographics
NPI:1356310445
Name:VICKERS, EDWARD DEE JR
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:DEE
Last Name:VICKERS
Suffix:JR
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:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33826-0150
Mailing Address - Country:US
Mailing Address - Phone:863-453-0684
Mailing Address - Fax:863-453-2873
Practice Address - Street 1:1116 BILLY MARTIN RD
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-4858
Practice Address - Country:US
Practice Address - Phone:863-453-0684
Practice Address - Fax:863-453-2873
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 5189111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL380135700Medicaid
FLU12108Medicare UPIN
FL380135700Medicaid