Provider Demographics
NPI:1790444834
Name:HICKS, GLASTER WHEELER
Entity Type:Individual
Prefix:MR
First Name:GLASTER
Middle Name:WHEELER
Last Name:HICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 398706
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75339-8706
Mailing Address - Country:US
Mailing Address - Phone:214-850-8318
Mailing Address - Fax:
Practice Address - Street 1:5117 ROCKY RIDGE RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75241-1023
Practice Address - Country:US
Practice Address - Phone:214-434-1583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX308453310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility