Provider Demographics
NPI:1083261143
Name:VINDIVICH, NICK GEORGE III (BA)
Entity Type:Individual
Prefix:
First Name:NICK
Middle Name:GEORGE
Last Name:VINDIVICH
Suffix:III
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 MERIDIAN PKWY STE 103
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25404-5422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 EMMETT ROUSCH DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-6313
Practice Address - Country:US
Practice Address - Phone:304-262-9831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)