Provider Demographics
NPI:1154331197
Name:NICKLESS, PETER GEORGE (DC)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:GEORGE
Last Name:NICKLESS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3239 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SENECA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13148-9416
Mailing Address - Country:US
Mailing Address - Phone:845-367-1171
Mailing Address - Fax:
Practice Address - Street 1:3239 LAKE RD
Practice Address - Street 2:
Practice Address - City:SENECA FALLS
Practice Address - State:NY
Practice Address - Zip Code:13148-9416
Practice Address - Country:US
Practice Address - Phone:845-367-1171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009869111N00000X
MECR1900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC09869-1OtherWORKERS COMP ID NUMBER
NYX009869OtherNY STATE LICENSE
MECR1900OtherMAINE LISCENCE
NYC09869-1OtherWORKERS COMP ID NUMBER