Provider Demographics
NPI:1073021242
Name:NICKL LABS
Entity Type:Organization
Organization Name:NICKL LABS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-923-0012
Mailing Address - Street 1:6310 DELAWARE ST STE 122
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-7646
Mailing Address - Country:US
Mailing Address - Phone:409-923-0012
Mailing Address - Fax:409-291-8010
Practice Address - Street 1:6310 DELAWARE ST STE 122
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-7646
Practice Address - Country:US
Practice Address - Phone:409-923-0012
Practice Address - Fax:409-291-8010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCL5957OtherBLUE CROSS BLUE SHIELD