Basic Information
| Provider Information | |||||||||
| NPI: | 1568852689 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HICKS | ||||||||
| FirstName: | MARTIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1552 W 49TH ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900622410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232937854 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 WILSHIRE BLVD FL 5 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900574303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136390230 | ||||||||
| FaxNumber: | 2133652813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2015 | ||||||||
| LastUpdateDate: | 02/03/2015 | ||||||||
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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 | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.