Provider Demographics
NPI:1033806104
Name:DICKS, NICKOLAS JAMES
Entity Type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:JAMES
Last Name:DICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5683 W HAMMOND AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-8609
Mailing Address - Country:US
Mailing Address - Phone:559-903-3452
Mailing Address - Fax:
Practice Address - Street 1:1649 VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1128
Practice Address - Country:US
Practice Address - Phone:888-530-4415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86085300133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered