Provider Demographics
NPI:1871144816
Name:DJPNICOLAS, LLC
Entity type:Organization
Organization Name:DJPNICOLAS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CENTER DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-691-6031
Mailing Address - Street 1:144 N. GRAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741
Mailing Address - Country:US
Mailing Address - Phone:626-691-6031
Mailing Address - Fax:
Practice Address - Street 1:144 N. GRAND AVENUE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741
Practice Address - Country:US
Practice Address - Phone:626-691-6031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center