Provider Demographics
NPI:1104689942
Name:HICKS, TY (DC)
Entity type:Individual
Prefix:
First Name:TY
Middle Name:
Last Name:HICKS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEBB CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64870-1936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WEBB CITY
Practice Address - State:MO
Practice Address - Zip Code:64870-1936
Practice Address - Country:US
Practice Address - Phone:417-540-6651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024002956111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor