Provider Demographics
NPI:1164050928
Name:HOLBROOK, NICHOLAS WILLIAM
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:WILLIAM
Last Name:HOLBROOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10511 S ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-3912
Mailing Address - Country:US
Mailing Address - Phone:708-307-0220
Mailing Address - Fax:
Practice Address - Street 1:10511 S ROBERTS RD
Practice Address - Street 2:
Practice Address - City:PALOS HILLS
Practice Address - State:IL
Practice Address - Zip Code:60465-3912
Practice Address - Country:US
Practice Address - Phone:708-307-0220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-28
Last Update Date:2020-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program