1275773111 NPI number — MRS. NICHOLE MARIE EICKHOLT MSPT

Table of content: MRS. NICHOLE MARIE EICKHOLT MSPT (NPI 1275773111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275773111 NPI number — MRS. NICHOLE MARIE EICKHOLT MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EICKHOLT
Provider First Name:
NICHOLE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSPT
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:
1275773111
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17272 ROBBINS RD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
GRAND HAVEN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-733-1200
Provider Business Mailing Address Fax Number:
810-733-3130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17272 ROBBINS RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
GRAND HAVEN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-733-1200
Provider Business Practice Location Address Fax Number:
810-733-3130
Provider Enumeration Date:
03/05/2009

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: 225100000X , with the licence number:  5501012916 , 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)

  • Identifier: 0N45090 . This is a "MEDICARE GRP PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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