Provider Demographics
NPI:1356358253
Name:VICK, LARRY B (DC)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:B
Last Name:VICK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:916 TALON DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OFALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1848
Mailing Address - Country:US
Mailing Address - Phone:618-628-8211
Mailing Address - Fax:618-628-0883
Practice Address - Street 1:916 TALON DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:OFALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1848
Practice Address - Country:US
Practice Address - Phone:618-628-8211
Practice Address - Fax:618-628-0883
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL038003709111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08220357OtherBCBS GRP#
IL900068033OtherTAX ID#
IL900068033OtherTAX ID#
IL207465Medicare PIN