Provider Demographics
NPI:1154428860
Name:NICKUM, KIRK RYAN (DC)
Entity type:Individual
Prefix:DR
First Name:KIRK
Middle Name:RYAN
Last Name:NICKUM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5650 W FLAMINGO RD
Mailing Address - Street 2:SUITE #A
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-0172
Mailing Address - Country:US
Mailing Address - Phone:702-368-3910
Mailing Address - Fax:702-871-4729
Practice Address - Street 1:5650 W FLAMINGO RD
Practice Address - Street 2:SUITE #A
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-0172
Practice Address - Country:US
Practice Address - Phone:702-368-3910
Practice Address - Fax:702-871-4729
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB00420111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VDC420Medicare UPIN