Healthcare Provider Details

I. General information

NPI: 1104552082
Provider Name (Legal Business Name): NICKY DARRELL KITCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2022
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2770 S MARYLAND PKWY STE 213A
LAS VEGAS NV
89109-1565
US

IV. Provider business mailing address

4880 SANTA BARBARA ST UNIT 319
LAS VEGAS NV
89121-6168
US

V. Phone/Fax

Practice location:
  • Phone: 702-331-0100
  • Fax:
Mailing address:
  • Phone: 702-236-7579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: