Provider Demographics
NPI:1881295996
Name:NICKEL CITY GROUP, LLC
Entity type:Organization
Organization Name:NICKEL CITY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:LAVAR
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-281-1150
Mailing Address - Street 1:1581 E DELAVAN AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-3629
Mailing Address - Country:US
Mailing Address - Phone:716-281-1150
Mailing Address - Fax:
Practice Address - Street 1:1581 E DELAVAN AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3629
Practice Address - Country:US
Practice Address - Phone:716-281-1150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06085390Medicaid