Provider Demographics
NPI:1699964098
Name:TED M. NICKLAUS
Entity type:Organization
Organization Name:TED M. NICKLAUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL RECORDS ADMIN
Authorized Official - Prefix:MS
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:KLAGGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-463-5111
Mailing Address - Street 1:PO BOX 7066
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79114-7066
Mailing Address - Country:US
Mailing Address - Phone:806-463-5111
Mailing Address - Fax:806-463-5223
Practice Address - Street 1:101 WALLACE BLVD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106
Practice Address - Country:US
Practice Address - Phone:806-355-7453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2007-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD2283314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00123NMedicare PIN