Provider Demographics
NPI:1477006054
Name:NICKES MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:NICKES MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NGOZI
Authorized Official - Middle Name:
Authorized Official - Last Name:AUSTIN-ELEJE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-633-3724
Mailing Address - Street 1:2820 N STANTON ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-2509
Mailing Address - Country:US
Mailing Address - Phone:915-633-3724
Mailing Address - Fax:
Practice Address - Street 1:215 EAST BROADWAY
Practice Address - Street 2:
Practice Address - City:VAN HORN
Practice Address - State:TX
Practice Address - Zip Code:79855
Practice Address - Country:US
Practice Address - Phone:432-283-1000
Practice Address - Fax:915-533-0078
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NICKES MEDICAL SUPPLY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-29
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0094093332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX187854801Medicaid
TX5823190001Medicare NSC