Provider Demographics
NPI:1821419011
Name:NICOSIA ENTERPRISES LLC
Entity Type:Organization
Organization Name:NICOSIA ENTERPRISES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHANDA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:NICOSIA
Authorized Official - Suffix:
Authorized Official - Credentials:LSA
Authorized Official - Phone:903-566-6816
Mailing Address - Street 1:13674 ARIZONA DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75707-6806
Mailing Address - Country:US
Mailing Address - Phone:903-566-6816
Mailing Address - Fax:972-268-6014
Practice Address - Street 1:13674 ARIZONA DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75707-6806
Practice Address - Country:US
Practice Address - Phone:903-566-6816
Practice Address - Fax:972-268-6014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-15
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00471246ZC0007X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty