Healthcare Provider Details

I. General information

NPI: 1699964098
Provider Name (Legal Business Name): TED M. NICKLAUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 11/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WALLACE BLVD
AMARILLO TX
79106
US

IV. Provider business mailing address

PO BOX 7066
AMARILLO TX
79114-7066
US

V. Phone/Fax

Practice location:
  • Phone: 806-355-7453
  • Fax:
Mailing address:
  • Phone: 806-463-5111
  • Fax: 806-463-5223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberD2283
License Number StateTX

VIII. Authorized Official

Name: MS. CONSTANCE SUE KLAGGE
Title or Position: MEDICAL RECORDS ADMIN
Credential:
Phone: 806-463-5111