MEDICARE: AIKKIKO NICKLER IDC

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	390200000X	Student in an Organized Health Care Education/Training Program
2	1710I1002X	Independent Duty Corpsman	1336722685	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1336722685	OTHER		TRICARE

General Provider Information

NPI Number	:	1336722685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AIKKIKO NICKLER IDC

Provider Business Mailing Address
First Line	:	1741 ORO VISTA RD APT 245
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92154-4507
Country	:	US
Telephone Number	:	475-224-8659
Fax Number	:

Provider Business Practice Location Address
First Line	:	1741 ORO VISTA RD APT 245
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92154-4507
Country	:	US
Telephone Number	:	475-224-8659
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2021
Last Update Date	:	01/20/2022

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Directions to “ AIKKIKO NICKLER IDC” Practice Location

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