Healthcare Provider Details

I. General information

NPI: 1124119748
Provider Name (Legal Business Name): JOHN NICKELS RVT/RDMS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2474 INDIAN WELLS RD
ALAMOGORDO NM
88310-3831
US

IV. Provider business mailing address

PO BOX 247
ALAMOGORDO NM
88311-0247
US

V. Phone/Fax

Practice location:
  • Phone: 505-443-0339
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: