1437140357 NPI number — MR. GARY DALE NICHOLS P.A.-C

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 1437140357 NPI number — MR. GARY DALE NICHOLS P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLS
Provider First Name:
GARY
Provider Middle Name:
DALE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C
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:
1437140357
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
191 PRIVATE ROAD 845
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEAGUE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75860-6081
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-625-0310
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16TH STREET
Provider Second Line Business Practice Location Address:
CTMC, BLDG 885
Provider Business Practice Location Address City Name:
FORT LEONARD WOOD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-596-1680
Provider Business Practice Location Address Fax Number:
573-596-0423
Provider Enumeration Date:
10/31/2005

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: 363A00000X , with the licence number:  PA02338 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PA02338 . This is a "STATE LICENSE/PERMIT" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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