Healthcare Provider Details

I. General information

NPI: 1619539335
Provider Name (Legal Business Name): NICKES MEDICAL SUPPLY, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5443 DUDLEY BLVD BLDG 911
MCCLELLAN CA
95652-1013
US

IV. Provider business mailing address

2820 N STANTON ST
EL PASO TX
79902-2509
US

V. Phone/Fax

Practice location:
  • Phone: 915-533-8870
  • Fax: 915-533-0078
Mailing address:
  • Phone: 915-533-8870
  • Fax: 915-533-0078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: NGOZI KATHLEEN AUSTIN-ELEJE
Title or Position: OWNER/MANAGER
Credential:
Phone: 915-533-8870