Provider Demographics
NPI:1447430905
Name:HICKS, CHARLES
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:HICKS
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 1:111 NW 183RD ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-4537
Mailing Address - Country:US
Mailing Address - Phone:305-892-4753
Mailing Address - Fax:305-493-0814
Practice Address - Street 1:111 NW 183RD ST
Practice Address - Street 2:SUITE 400
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33169-4537
Practice Address - Country:US
Practice Address - Phone:305-892-4753
Practice Address - Fax:305-493-0814
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5162196164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse