Provider Demographics
NPI:1508209214
Name:KEVIN NICHOLSON LLC
Entity Type:Organization
Organization Name:KEVIN NICHOLSON LLC
Other - Org Name:DOCTOR 2 YOUR DOOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TANSYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-545-9191
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:LOUGHMAN
Mailing Address - State:FL
Mailing Address - Zip Code:33858-0407
Mailing Address - Country:US
Mailing Address - Phone:407-545-9191
Mailing Address - Fax:
Practice Address - Street 1:1674 PLEASANT HILL RD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-3954
Practice Address - Country:US
Practice Address - Phone:407-545-9191
Practice Address - Fax:407-641-8918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME101521208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty