Provider Demographics
NPI:1407381940
Name:HEATHER HICKSON LAC LLC
Entity type:Organization
Organization Name:HEATHER HICKSON LAC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:M
Authorized Official - Last Name:HICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-461-7529
Mailing Address - Street 1:5353 NORTH FEDERAL HIGHWAY
Mailing Address - Street 2:STE 220
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308
Mailing Address - Country:US
Mailing Address - Phone:954-461-7529
Mailing Address - Fax:
Practice Address - Street 1:5353 NORTH FEDERAL HIGHWAY
Practice Address - Street 2:STE 220
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308
Practice Address - Country:US
Practice Address - Phone:954-461-7529
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3408261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service