Provider Demographics
NPI:1407997547
Name:NICHOLS, MARK EDWARD (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:EDWARD
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 FORREST RD
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9341
Mailing Address - Country:US
Mailing Address - Phone:304-562-7637
Mailing Address - Fax:
Practice Address - Street 1:2900 1ST AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1241
Practice Address - Country:US
Practice Address - Phone:304-526-1333
Practice Address - Fax:304-526-1335
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV02111225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist