MEDICARE: MR. TIMOTHY DEAN NIKKEL

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	343900000X	Non-emergency Medical Transport (VAN)	882ZZ1895	IA

General Provider Information

NPI Number	:	1578865622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TIMOTHY DEAN NIKKEL

Provider Business Mailing Address
First Line	:	5011 MORNINGSIDE AVE.
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51106-3027
Country	:	US
Telephone Number	:	712-224-4722
Fax Number	:	186-635-8636

Provider Business Practice Location Address
First Line	:	5011 MORNINGSIDE AVE
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51106-3027
Country	:	US
Telephone Number	:	712-224-4722
Fax Number	:	186-635-8636

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

Provider Enumeration Date	:	11/23/2010
Last Update Date	:	11/23/2010

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