Provider Demographics
NPI:1376866954
Name:HICKOK REHAB SERVICES LLC
Entity Type:Organization
Organization Name:HICKOK REHAB SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HICKOK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:715-925-2471
Mailing Address - Street 1:831 DALLAS ST
Mailing Address - Street 2:
Mailing Address - City:CHETEK
Mailing Address - State:WI
Mailing Address - Zip Code:54728-5811
Mailing Address - Country:US
Mailing Address - Phone:715-925-2471
Mailing Address - Fax:
Practice Address - Street 1:831 DALLAS ST
Practice Address - Street 2:
Practice Address - City:CHETEK
Practice Address - State:WI
Practice Address - Zip Code:54728-5811
Practice Address - Country:US
Practice Address - Phone:715-925-2471
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4639-024335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5336890001Medicare PIN