Provider Demographics
NPI:1508462359
Name:NICH'K BEAUTY RX
Entity Type:Organization
Organization Name:NICH'K BEAUTY RX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-758-5885
Mailing Address - Street 1:9300 CONROY WINDERMERE RD UNIT 3397
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-5158
Mailing Address - Country:US
Mailing Address - Phone:407-758-5885
Mailing Address - Fax:
Practice Address - Street 1:4909 RALEIGH STREET #7
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811
Practice Address - Country:US
Practice Address - Phone:407-758-5885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier