1205264793 NPI number — MICHAEL B NICHOLES L.M.T.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205264793 NPI number — MICHAEL B NICHOLES L.M.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLES
Provider First Name:
MICHAEL
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.M.T.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205264793
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9721 SE CLATSOP ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97266-6102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-336-0392
Provider Business Mailing Address Fax Number:
503-788-9974

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8810 SE SUNNYBROOK BLVD
Provider Second Line Business Practice Location Address:
STE #100
Provider Business Practice Location Address City Name:
CLACKAMAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97015-6843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-607-2226
Provider Business Practice Location Address Fax Number:
503-659-2276
Provider Enumeration Date:
10/22/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  17302 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)