1548656366 NPI number — NICHOLE ROOST OTR/L

Table of content: NICHOLE ROOST OTR/L (NPI 1548656366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548656366 NPI number — NICHOLE ROOST OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROOST
Provider First Name:
NICHOLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
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:
1548656366
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 SOLAR DR
Provider Second Line Business Mailing Address:
SUITE 180
Provider Business Mailing Address City Name:
OXNARD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93036-2645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-605-1924
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 W FRONT ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRAVERSE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49684-2287
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-346-4045
Provider Business Practice Location Address Fax Number:
231-935-8000
Provider Enumeration Date:
04/08/2015

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: 225XH1200X , with the licence number:  15181 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XH1200X , with the licence number: 5201011112 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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