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Organization
ST NICHOLAS PROVIDER SERVICES INC
Active
Organization
ST NICHOLAS PROVIDER SERVICES INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. OLUFESOLA M FASAKIN RN (ADMINISTRATOR)
(817) 468-9006
Entity
Organization
Contact information
Practice address
7008 LAKE JACKSON DR, ARLINGTON, TX 76002-4054
(817) 468-9006
(817) 468-9006
Mailing address
7008 LAKE JACKSON DR, ARLINGTON, TX 76002-4054
(817) 468-9006
(817) 468-9006
Taxonomy
Speciality
Code
Description
License number
State
251E00000X
Home Health Agency
Primary
010407
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
010407
STATE HOME HEALTH LICENSE
TX
05
—
205352201
—
TX
Enumeration date
07/17/2006
Last updated
07/19/2010
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