Provider Demographics
NPI:1336309731
Name:HICKS, PETER LORNE CONRAD (DC)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:LORNE CONRAD
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 1:2300 GREAT NORTHERN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1678
Mailing Address - Country:US
Mailing Address - Phone:406-549-7171
Mailing Address - Fax:406-549-6868
Practice Address - Street 1:2300 GREAT NORTHERN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1678
Practice Address - Country:US
Practice Address - Phone:406-549-7171
Practice Address - Fax:406-549-6868
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1207111N00000X
MS1142111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1336309731OtherNPI
MT1861759011OtherNPI