Healthcare Provider Details

I. General information

NPI: 1154734267
Provider Name (Legal Business Name): NICHOLE NINO O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E PINE ST
EXETER CA
93221-1844
US

IV. Provider business mailing address

640 BOSTON ST
HEMET CA
92545-2304
US

V. Phone/Fax

Practice location:
  • Phone: 559-592-3121
  • Fax:
Mailing address:
  • Phone: 951-259-9717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14924
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: