Provider Demographics
NPI:1760992267
Name:HICKS, LEONARD JOSEPH (LAC)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:JOSEPH
Last Name:HICKS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 N FRANCISCA AVE APT C
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-7306
Mailing Address - Country:US
Mailing Address - Phone:310-844-7261
Mailing Address - Fax:
Practice Address - Street 1:510 N FRANCISCA AVE APT C
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-7306
Practice Address - Country:US
Practice Address - Phone:310-480-9461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17838171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist