1366676207 NPI number — CARRIE A NICHOLAS D.C.

Table of content: CARRIE A NICHOLAS D.C. (NPI 1366676207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366676207 NPI number — CARRIE A NICHOLAS D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLAS
Provider First Name:
CARRIE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
F

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:
1366676207
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8117 NEW LA GRANGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40222-4637
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-326-9950
Provider Business Mailing Address Fax Number:
502-326-9952

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8117 NEW LA GRANGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40222-4637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-326-9950
Provider Business Practice Location Address Fax Number:
502-326-9952
Provider Enumeration Date:
05/06/2009

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: 111N00000X , with the licence number:  3387 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 5381 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100237860 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".