Provider Demographics
NPI:1063070357
Name:VICK, TANNER JAMES (ATC)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:JAMES
Last Name:VICK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67505-1950
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:404 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:SOUTH HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67505-1950
Practice Address - Country:US
Practice Address - Phone:620-921-1307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer