Provider Demographics
NPI:1750718201
Name:IRENE M. NICOLAIDES INC.
Entity type:Organization
Organization Name:IRENE M. NICOLAIDES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:M
Authorized Official - Last Name:NICOLAIDES
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:516-499-7090
Mailing Address - Street 1:2318 31ST STREET
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105
Mailing Address - Country:US
Mailing Address - Phone:516-499-7090
Mailing Address - Fax:516-799-7009
Practice Address - Street 1:4616 BELMONT ROAD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11020
Practice Address - Country:US
Practice Address - Phone:516-499-7090
Practice Address - Fax:516-499-7009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005735.1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06971Medicare UPIN