Provider Demographics
NPI:1003221185
Name:NICOLEX LLC
Entity Type:Organization
Organization Name:NICOLEX LLC
Other - Org Name:MOON VALLEY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:623-330-8723
Mailing Address - Street 1:14435 N 7TH ST
Mailing Address - Street 2:STE 104
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-4371
Mailing Address - Country:US
Mailing Address - Phone:602-993-2727
Mailing Address - Fax:602-449-0681
Practice Address - Street 1:14435 N 7TH ST
Practice Address - Street 2:STE 104
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-4371
Practice Address - Country:US
Practice Address - Phone:602-993-2727
Practice Address - Fax:602-449-0681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-26
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ1210152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ747561Medicaid
AZZ144738Medicare PIN