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Organization

UNITED STATES NAVY

Active
Organization subpart
No

Provider details

NPI number
Authorized official
SHANE C HICKS IDC (INDEPENDENT DUTY CORPSMAN)
(843) 574-8242
Entity
Organization

Contact information

Practice address
3600 RIVERS AVE, CHARLESTON, WA 29405
(843) 574-8242
Mailing address
48 HICKORY HALL LN, GOOSE CREEK, SC 29445-6318
(360) 689-9072

Taxonomy

Speciality
Code
Description
License number
State
261QM1103X
Military Ambulatory Procedure Visits Operational (Transportable) Clinic/Center
Primary
TX

Other

Enumeration date
04/03/2009
Last updated
07/21/2022
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