Provider Demographics
NPI:1376743344
Name:NICKS SERVICE
Entity Type:Organization
Organization Name:NICKS SERVICE
Other - Org Name:NICKS SERVICE
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROCKY
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-523-5060
Mailing Address - Street 1:367 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3639
Mailing Address - Country:US
Mailing Address - Phone:208-523-5060
Mailing Address - Fax:208-524-7203
Practice Address - Street 1:367 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3639
Practice Address - Country:US
Practice Address - Phone:208-523-5060
Practice Address - Fax:208-524-7203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806670000Medicaid
ID806670000Medicaid