Provider Demographics
NPI:1457703340
Name:LICINA, TINA (OD)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:LICINA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5840 W. CRAIG RD.
Mailing Address - Street 2:STE. 120 PMB 254
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130
Mailing Address - Country:US
Mailing Address - Phone:702-724-2020
Mailing Address - Fax:702-405-5541
Practice Address - Street 1:5871 W. CRAIG RD.
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130
Practice Address - Country:US
Practice Address - Phone:702-724-2020
Practice Address - Fax:702-724-2800
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NV915152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program