Healthcare Provider Details

I. General information

NPI: 1649655085
Provider Name (Legal Business Name): SOFIA TICAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2015
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 W CHARLESTON BLVD STE 101
LAS VEGAS NV
89146-1067
US

IV. Provider business mailing address

6600 W CHARLESTON BLVD STE 101
LAS VEGAS NV
89146-1067
US

V. Phone/Fax

Practice location:
  • Phone: 702-690-1865
  • Fax:
Mailing address:
  • Phone: 702-690-1865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberNVMT6406
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number680240156
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: