Provider Demographics
NPI:1881687374
Name:NICKSE, STEPHEN S (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:S
Last Name:NICKSE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10863 PARK BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-5423
Mailing Address - Country:US
Mailing Address - Phone:727-399-2229
Mailing Address - Fax:727-399-2228
Practice Address - Street 1:10863 PARK BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-5423
Practice Address - Country:US
Practice Address - Phone:727-399-2229
Practice Address - Fax:727-399-2228
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH #0007165111N00000X
FLCH0007165111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL55540OtherBCBS ID#
FLHCC 2141OtherFL CLINIC LICENSE #
FLCH #0007165OtherFL LICENSE #
FL381927200Medicaid
FL55540OtherBC/BS
FL55540OtherBCBS ID#
FL55540OtherBC/BS