Provider Demographics
NPI:1922366129
Name:NIKAS, DESMA S
Entity Type:Individual
Prefix:
First Name:DESMA
Middle Name:S
Last Name:NIKAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:LAKE ARROWHEAD
Mailing Address - State:CA
Mailing Address - Zip Code:92352-0969
Mailing Address - Country:US
Mailing Address - Phone:909-867-9083
Mailing Address - Fax:909-867-9086
Practice Address - Street 1:28200 HIGHWAY 189
Practice Address - Street 2:BLDG R-110
Practice Address - City:LAKE ARROWHEAD
Practice Address - State:CA
Practice Address - Zip Code:92352-9700
Practice Address - Country:US
Practice Address - Phone:909-867-9083
Practice Address - Fax:909-867-9086
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor