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General NPI Number Information
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NPI Number | 1013934751
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Entity Type | Organization
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Legal Business Name | ST NICHOLAS PROVIDER SERVICES INC
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Dates
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Enumeration Date | 07/17/2006
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Last Update Date | 07/19/2010
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Provider Practice Location Address
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Address Line | 7008 LAKE JACKSON DR
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City | ARLINGTON
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State | TX
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Zip | 76002-4054
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Country | US
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Telephone | 817-468-9006
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Fax | 817-468-9006
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Provider Business Mailing Address
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Address Line | 7008 LAKE JACKSON DR
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City | ARLINGTON
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State | TX
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Zip | 76002-4054
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Country | US
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Telephone | 817-468-9006
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Fax | 817-468-9006
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. OLUFESOLA M FASAKIN
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Credential | RN
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Telephone | 817-468-9006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 010407
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License Number State | TX
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