Provider Demographics
NPI:1518734482
Name:DEWALD, NICHOLAS JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JOSEPH
Last Name:DEWALD
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 1:12894 GANNET CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1285
Mailing Address - Country:US
Mailing Address - Phone:260-442-6025
Mailing Address - Fax:
Practice Address - Street 1:9614 LIMA RD STE 104
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-9279
Practice Address - Country:US
Practice Address - Phone:260-442-6025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08003397A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor