Provider Demographics
NPI:1912500588
Name:DICKENS, MICHAEL JR
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DICKENS
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 1:2427 BOGUS RD SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON COURT HOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43160-8707
Mailing Address - Country:US
Mailing Address - Phone:614-747-9733
Mailing Address - Fax:
Practice Address - Street 1:2427 BOGUS RD SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON COURT HOUSE
Practice Address - State:OH
Practice Address - Zip Code:43160-8707
Practice Address - Country:US
Practice Address - Phone:614-747-9733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2400795374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide