1104137751 NPI number — TRAVIS J NICHOLS DPT

Table of content: TRAVIS J NICHOLS DPT (NPI 1104137751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104137751 NPI number — TRAVIS J NICHOLS DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLS
Provider First Name:
TRAVIS
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1104137751
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
426A MCCALL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANHATTAN
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66502-5032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-776-0670
Provider Business Mailing Address Fax Number:
785-776-0096

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4201B ANDERSON AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
MANHATTAN
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66503-7601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-539-5555
Provider Business Practice Location Address Fax Number:
785-539-4551
Provider Enumeration Date:
06/29/2010

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: 2251X0800X , with the licence number:  0012597 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 1103824 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: KA2868020 . This is a "MEDICARE PTAN" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 1104037751 . This is a "BCBS KS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 44204046 . This is a "BCBS KC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 201182370A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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