Provider Demographics
NPI:1639227481
Name:VICKERS, MARVIN KERON III (DC)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:KERON
Last Name:VICKERS
Suffix:III
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 1:6005 RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242
Mailing Address - Country:US
Mailing Address - Phone:205-995-0340
Mailing Address - Fax:
Practice Address - Street 1:3940 GRANTS MILL RD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35210-1204
Practice Address - Country:US
Practice Address - Phone:205-951-2204
Practice Address - Fax:205-951-2242
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1933111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALU80955OtherVIVA
AL4410443OtherUNITED HEALTHCARE
AL90508Medicare UPIN
AL4410443OtherUNITED HEALTHCARE