Provider Demographics
NPI:1760424113
Name:HICKOK REHABILITATION SERVICES, LLC
Entity Type:Organization
Organization Name:HICKOK REHABILITATION SERVICES, LLC
Other - Org Name:DUNAMIS THERAPY & FITNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PHYSICAL THERAPIST
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:715-286-2203
Mailing Address - Street 1:P.O. BOX 418
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:WI
Mailing Address - Zip Code:54722
Mailing Address - Country:US
Mailing Address - Phone:715-286-2203
Mailing Address - Fax:715-286-2076
Practice Address - Street 1:836 RICHARD DR
Practice Address - Street 2:SUITE B
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6242
Practice Address - Country:US
Practice Address - Phone:715-834-5850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4639-022251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI601601600OtherUS DEPT OF LABOR
WI7397OtherGROUP HEALTH
WI000081145OtherMEDICARE PTAN FOR THORP & CHETEK
WI68848OtherSECURITY HEALTH PLAN
WI533689001OtherDME MEDICARE
WI7398OtherGROUP HEALTH
WI40253000Medicaid
WI5336890002OtherDME PROVIDER #
WI533689001OtherDME MEDICARE
WIP00109397Medicare ID - Type UnspecifiedRR MEDICARE
WI7398OtherGROUP HEALTH
WI533689002Medicare NSC
WIP00109397Medicare ID - Type UnspecifiedRR MEDICARE
WI533689001OtherDME MEDICARE