Provider Demographics
NPI:1750391561
Name:NICKI A. WALL PC
Entity type:Organization
Organization Name:NICKI A. WALL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF OPTOMETRY
Authorized Official - Prefix:DR
Authorized Official - First Name:NICKI
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:281-534-2020
Mailing Address - Street 1:3600 GULF FWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:DICKINSON
Mailing Address - State:TX
Mailing Address - Zip Code:77539-4123
Mailing Address - Country:US
Mailing Address - Phone:281-534-2020
Mailing Address - Fax:281-614-0335
Practice Address - Street 1:3600 GULF FWY
Practice Address - Street 2:SUITE A
Practice Address - City:DICKINSON
Practice Address - State:TX
Practice Address - Zip Code:77539-4123
Practice Address - Country:US
Practice Address - Phone:281-534-2020
Practice Address - Fax:281-614-0335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX04000TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherTAX IDENTIFICATION NUMBER