1174502645 NPI number — MR. NIKOLOS WILLIAM BOEHMER PT, DPT

Table of content: MR. NIKOLOS WILLIAM BOEHMER PT, DPT (NPI 1174502645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174502645 NPI number — MR. NIKOLOS WILLIAM BOEHMER PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOEHMER
Provider First Name:
NIKOLOS
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT, 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:
1174502645
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4330 SOUTHPORT SUPPLY ROAD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
SOUTHPORT
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-457-0113
Provider Business Mailing Address Fax Number:
910-457-0114

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4330 SOUTHPORT SUPPLY ROAD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SOUTHPORT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-457-0113
Provider Business Practice Location Address Fax Number:
910-457-0114
Provider Enumeration Date:
01/12/2006

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: 225100000X , with the licence number:  10175 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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