MEDICARE: MR. VICTOR DALE NIKIRK OTR OPA-C

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	225X00000X	Occupational Therapist	000402	NY

General Provider Information

NPI Number	:	1477506418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VICTOR DALE NIKIRK OTR OPA-C

Provider Business Mailing Address
First Line	:	576 SUNRISE HWY
Second Line	:
City	:	WEST BABYLON
State	:	NY
Zip	:	11704-6003
Country	:	US
Telephone Number	:	631-376-0318
Fax Number	:	631-376-0319

Provider Business Practice Location Address
First Line	:	285 SILLS ROAD
Second Line	:	BLDG 18
City	:	EAST PATCHOGUE
State	:	NY
Zip	:	11772-4808
Country	:	US
Telephone Number	:	631-475-1224
Fax Number	:	631-475-1224

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

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	08/15/2008

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