1417130766 NPI number — NIKOLA BICAK

Table of content: (NPI 1417130766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417130766 NPI number — NIKOLA BICAK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NIKOLA BICAK
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417130766
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 796
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIPLEY
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25271-0796
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-372-3788
Provider Business Mailing Address Fax Number:
304-372-1513

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1837 RIPLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIPLEY
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25271-5113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-372-3788
Provider Business Practice Location Address Fax Number:
304-372-1513
Provider Enumeration Date:
12/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BICAK
Authorized Official First Name:
LORI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
BILLING
Authorized Official Telephone Number:
304-372-3788

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  307 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0099957000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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