NPIMap

Organization Active NPI

Nicolex LLC

  • Optometrist
  • Phoenix, AZ
National Provider Identifier
1003221185
Registry record updated Mar 13, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
License
AZ1210 Issued in AZ
Legal business name
NICOLEX LLC
Practice address
14435 N 7TH St
Ste 104
Phoenix, AZ 85022-4371
Phone
(602) 993-2727
Fax
(602) 449-0681
NPI assigned
Jun 26, 2014
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 13, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Jesse Vincent Dominguez, ODNPI 1669789814
Title
President
Phone
(623) 330-8723

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193400000X SINGLE SPECIALTY GROUP 152W00000X AZ1210 AZ Primary

Addresses

Primary practice location

14435 N 7TH St
Ste 104
Phoenix, AZ 85022-4371

Mailing address

14435 N 7TH St
Ste 104
Phoenix, AZ 85022-4371
Phone (602) 993-2727

Other identifiers 1

IdentifierTypeStateIssuer
747561MedicaidAZ

Other names 1

  • Moon Valley Eyecare Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150629002559 AZ Part B Supplier - Clinic/Group Practice 3870805179 Receives reassigned benefits from 2 practitioners
Practice locations: Phoenix, AZ

National Provider Directory

National Provider Directory
Tax ID family
Moon Valley Eyecare2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

14435 N 7th St
Ste 205
Phoenix, AZ 85022

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1403740800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1426204800000",
    "number": "1003221185",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "14435 N 7TH ST",
            "address_2": "STE 104",
            "city": "PHOENIX",
            "state": "AZ",
            "postal_code": "850224371",
            "telephone_number": "602-993-2727",
            "fax_number": "602-449-0681"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "14435 N 7TH ST",
            "address_2": "STE 104",
            "city": "PHOENIX",
            "state": "AZ",
            "postal_code": "850224371",
            "telephone_number": "602-993-2727",
            "fax_number": "602-449-0681"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NICOLEX LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-06-26",
        "last_updated": "2015-03-13",
        "status": "A",
        "authorized_official_last_name": "DOMINGUEZ",
        "authorized_official_first_name": "JESSE",
        "authorized_official_middle_name": "VINCENT",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "623-330-8723",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "OD"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": "AZ",
            "license": "AZ1210",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "747561",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Moon Valley Eyecare",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Phoenix, AZ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 13, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.