Provider Demographics
NPI:1154734267
Name:NINO, NICHOLE (OD)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:NINO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 BOSTON ST
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-2304
Mailing Address - Country:US
Mailing Address - Phone:951-259-9717
Mailing Address - Fax:
Practice Address - Street 1:400 E PINE ST
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:CA
Practice Address - Zip Code:93221-1844
Practice Address - Country:US
Practice Address - Phone:559-592-3121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14924152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA567276Medicaid