Provider Demographics
NPI:1083905277
Name:JEFF NICHOLL PHYSICAL THERAPY & SPORTS REHABILITATION, INC.
Entity Type:Organization
Organization Name:JEFF NICHOLL PHYSICAL THERAPY & SPORTS REHABILITATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-388-5678
Mailing Address - Street 1:PO BOX 3783
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93006-3783
Mailing Address - Country:US
Mailing Address - Phone:805-388-5678
Mailing Address - Fax:805-388-5665
Practice Address - Street 1:516 LAS POSAS RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-5705
Practice Address - Country:US
Practice Address - Phone:805-388-5678
Practice Address - Fax:805-388-5665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA177392251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty