Provider Demographics
NPI:1689930547
Name:HICKS HOUSE OF CARE
Entity Type:Organization
Organization Name:HICKS HOUSE OF CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNERS
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-681-1653
Mailing Address - Street 1:2611 ZOLA DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-2613
Mailing Address - Country:US
Mailing Address - Phone:336-681-1653
Mailing Address - Fax:
Practice Address - Street 1:2611 ZOLA DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-2613
Practice Address - Country:US
Practice Address - Phone:336-681-1653
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HICKS HOUSE OF CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-05
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-1026320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities