Provider Demographics
NPI:1063688893
Name:NIEC, GENE R (PTA)
Entity Type:Individual
Prefix:MR
First Name:GENE
Middle Name:R
Last Name:NIEC
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W8515 MERRIMAN WEST RD # B
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-9553
Mailing Address - Country:US
Mailing Address - Phone:906-779-1394
Mailing Address - Fax:
Practice Address - Street 1:W8515 MERRIMAN WEST RD # B
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-9553
Practice Address - Country:US
Practice Address - Phone:906-779-1394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1152-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40440800Medicaid