Provider Demographics
NPI:1184909327
Name:MICHAEL W. NICCOLE, MD, INC.
Entity type:Organization
Organization Name:MICHAEL W. NICCOLE, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-718-6900
Mailing Address - Street 1:1101 BAYSIDE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-1702
Mailing Address - Country:US
Mailing Address - Phone:949-718-6900
Mailing Address - Fax:949-718-9367
Practice Address - Street 1:1101 BAYSIDE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-1702
Practice Address - Country:US
Practice Address - Phone:949-718-6900
Practice Address - Fax:949-718-9367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30397174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty