Healthcare Provider Details

I. General information

NPI: 1831696301
Provider Name (Legal Business Name): NICKELIS VINCENT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 04/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34590 COUNTY LINE RD STE 7
YUCAIPA CA
92399-5398
US

IV. Provider business mailing address

3411 GRANDE VISTA PKWY APT 210
RIVERSIDE CA
92503-5532
US

V. Phone/Fax

Practice location:
  • Phone: 909-795-4255
  • Fax:
Mailing address:
  • Phone: 951-751-4794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: