Provider Demographics
NPI:1578626248
Name:ALLISON NICKLIN PT PC
Entity Type:Organization
Organization Name:ALLISON NICKLIN PT PC
Other - Org Name:REVOLUTION REHABILITATION INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:NICKLIN TOBIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT DPT MTC
Authorized Official - Phone:719-213-4911
Mailing Address - Street 1:155 PRINTERS PKWY
Mailing Address - Street 2:SUITE 125
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-6100
Mailing Address - Country:US
Mailing Address - Phone:719-635-8622
Mailing Address - Fax:719-635-8619
Practice Address - Street 1:155 PRINTERS PKWY
Practice Address - Street 2:SUITE 125
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-6100
Practice Address - Country:US
Practice Address - Phone:719-635-8622
Practice Address - Fax:719-635-8619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5237261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC806977OtherMEDICARE PTAN