Provider Demographics
NPI:1306021795
Name:NICHOLLS FAMILY HEALTH CARE, P.C.
Entity Type:Organization
Organization Name:NICHOLLS FAMILY HEALTH CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WINTON
Authorized Official - Middle Name:COPE
Authorized Official - Last Name:MCNAIR
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:678-778-8924
Mailing Address - Street 1:1205 VAN STREAT HWY
Mailing Address - Street 2:
Mailing Address - City:NICHOLLS
Mailing Address - State:GA
Mailing Address - Zip Code:31554-5025
Mailing Address - Country:US
Mailing Address - Phone:912-345-2474
Mailing Address - Fax:912-345-2518
Practice Address - Street 1:1205 VAN STREAT HWY
Practice Address - Street 2:
Practice Address - City:NICHOLLS
Practice Address - State:GA
Practice Address - Zip Code:31554-5025
Practice Address - Country:US
Practice Address - Phone:912-345-2474
Practice Address - Fax:912-345-2518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016807261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00274799AMedicaid
GA00274799AMedicaid