Provider Demographics
NPI:1295408516
Name:DAVIC, NICHOLAS (LAT,ATC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:DAVIC
Suffix:
Gender:M
Credentials:LAT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 LEGACY CT APT 159
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-5111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 E ARLINGTON BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5868
Practice Address - Country:US
Practice Address - Phone:252-565-8812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-47762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer