Basic Information
| Provider Information | |||||||||
| NPI: | 1356433742 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKS | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 84 S 362 W | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463859108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2194622744 | ||||||||
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| Practice Location | |||||||||
| Address1: | 47 PINE LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463503027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193250404 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 09/28/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18001631A | IN | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.