Provider Demographics
NPI:1760982128
Name:HICKERSON, CHAD R (MAOD)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:R
Last Name:HICKERSON
Suffix:
Gender:M
Credentials:MAOD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 SOQUEL AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1402
Mailing Address - Country:US
Mailing Address - Phone:831-600-2801
Mailing Address - Fax:
Practice Address - Street 1:2250 SOQUEL AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-1402
Practice Address - Country:US
Practice Address - Phone:831-600-2801
Practice Address - Fax:831-600-2801
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator