Provider Demographics
NPI:1679178271
Name:NICHOLAS MICKELSON LLC
Entity Type:Organization
Organization Name:NICHOLAS MICKELSON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAISA
Authorized Official - Middle Name:BICUDO
Authorized Official - Last Name:MICKELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-616-9019
Mailing Address - Street 1:8805 RUSTIC TRAIL CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33635-1557
Mailing Address - Country:US
Mailing Address - Phone:813-616-9019
Mailing Address - Fax:
Practice Address - Street 1:13612 W HILLSBOROUGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33635-9638
Practice Address - Country:US
Practice Address - Phone:813-444-7502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental