=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922366129
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DESMA S NIKAS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2012
-----------------------------------------------------
Last Update Date | 04/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28200 HIGHWAY 189 BLDG R-110
-----------------------------------------------------
City | LAKE ARROWHEAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92352-9700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-867-9083
-----------------------------------------------------
Fax | 909-867-9086
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 969
-----------------------------------------------------
City | LAKE ARROWHEAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92352-0969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-867-9083
-----------------------------------------------------
Fax | 909-867-9086
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171W00000X
-----------------------------------------------------
Taxonomy Name | Contractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------