Provider Demographics
NPI:1962883728
Name:M NICOLAS ENTERPRISE LLC
Entity type:Organization
Organization Name:M NICOLAS ENTERPRISE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT WORLD WIDE HEALTH SERVICE
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-268-2183
Mailing Address - Street 1:2500 METROCENTRE BLVD STE 8
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-3107
Mailing Address - Country:US
Mailing Address - Phone:800-409-3804
Mailing Address - Fax:800-268-2183
Practice Address - Street 1:2500 METROCENTRE BLVD STE 7-8
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-3107
Practice Address - Country:US
Practice Address - Phone:800-409-3804
Practice Address - Fax:800-268-2183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-17
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X, 261Q00000X, 261QD1600X, 385H00000X, 332U00000X
FL9397261QA0600X, 261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No385H00000XRespite Care FacilityRespite Care
No332U00000XSuppliersHome Delivered Meals
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115559600Medicaid
FL021834300Medicaid