1538436258 NPI number — MR. NICHOLAS LEE BOHANAN ATC, CSCS

Table of content: MR. NICHOLAS LEE BOHANAN ATC, CSCS (NPI 1538436258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538436258 NPI number — MR. NICHOLAS LEE BOHANAN ATC, CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOHANAN
Provider First Name:
NICHOLAS
Provider Middle Name:
LEE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
ATC, CSCS
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:
1538436258
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2708 MARTIN DR
Provider Second Line Business Mailing Address:
APT 3065
Provider Business Mailing Address City Name:
BEDFORD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76021-5044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-648-8525
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 SIX FLAGS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76011-6305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-385-8285
Provider Business Practice Location Address Fax Number:
817-385-8261
Provider Enumeration Date:
11/23/2011

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: 2255A2300X , with the licence number:  AT4733 , 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)





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