Provider Demographics
NPI:1992070056
Name:NICKJAX LLC
Entity type:Organization
Organization Name:NICKJAX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCUSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-738-9264
Mailing Address - Street 1:115 E 82ND ST
Mailing Address - Street 2:1B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0831
Mailing Address - Country:US
Mailing Address - Phone:212-738-9264
Mailing Address - Fax:
Practice Address - Street 1:115 E 82ND ST
Practice Address - Street 2:1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0831
Practice Address - Country:US
Practice Address - Phone:212-738-9264
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization