=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982927299
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NICKSTER, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2010
-----------------------------------------------------
Last Update Date | 07/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1514 AUSTIN AVE
-----------------------------------------------------
City | WACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76701-1712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-772-8660
-----------------------------------------------------
Fax | 800-240-7032
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1514 AUSTIN AVE
-----------------------------------------------------
City | WACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76701-1712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-772-8660
-----------------------------------------------------
Fax | 800-240-7032
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. ERIC SCHMELTEKOPF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 254-772-8660
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 008089
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------