Provider Demographics
NPI:1821861345
Name:HICKS, DWAYNE EVERETT JR
Entity Type:Individual
Prefix:MR
First Name:DWAYNE
Middle Name:EVERETT
Last Name:HICKS
Suffix:JR
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 1:1078 LAKE ROYALE
Mailing Address - Street 2:129 CHOCTAW DRIVE
Mailing Address - City:LOUISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27549
Mailing Address - Country:US
Mailing Address - Phone:252-425-7746
Mailing Address - Fax:
Practice Address - Street 1:1078 LAKE ROYALE
Practice Address - Street 2:129 CHOCTAW DRIVE
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549
Practice Address - Country:US
Practice Address - Phone:252-425-7746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities