MEDICARE: ST NICHOLAS PROVIDER SERVICES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	010407	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	010407	OTHER	TX	STATE HOME HEALTH LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013934751
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST NICHOLAS PROVIDER SERVICES INC

Provider Business Mailing Address
First Line	:	7008 LAKE JACKSON DR
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76002-4054
Country	:	US
Telephone Number	:	817-468-9006
Fax Number	:	817-468-9006

Provider Business Practice Location Address
First Line	:	7008 LAKE JACKSON DR
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76002-4054
Country	:	US
Telephone Number	:	817-468-9006
Fax Number	:	817-468-9006

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. OLUFESOLA M FASAKIN
Credential	:	RN
Telephone Number	:	817-468-9006

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	07/19/2010

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Directions to “ST NICHOLAS PROVIDER SERVICES INC ” Practice Location

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