Provider Demographics
NPI:1750439063
Name:NICACIO, LUIS MIGUEL (DC, CCSP)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:MIGUEL
Last Name:NICACIO
Suffix:
Gender:M
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2568 QUEENSGATE DRIVE
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352
Mailing Address - Country:US
Mailing Address - Phone:509-628-3745
Mailing Address - Fax:888-224-8375
Practice Address - Street 1:2568 QUEENSGATE DR.
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352
Practice Address - Country:US
Practice Address - Phone:509-628-3745
Practice Address - Fax:866-224-8375
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2916111NR0400X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU47832Medicare UPIN
WA391000211Medicare ID - Type Unspecified