Provider Demographics
NPI:1902295066
Name:BAZZY, NICK
Entity Type:Individual
Prefix:
First Name:NICK
Middle Name:
Last Name:BAZZY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5302 ROYAL VALE LN
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-4211
Mailing Address - Country:US
Mailing Address - Phone:248-885-7535
Mailing Address - Fax:
Practice Address - Street 1:5302 ROYAL VALE LN
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4211
Practice Address - Country:US
Practice Address - Phone:248-885-7535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2841972332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies