Provider Demographics
NPI:1588188221
Name:NICHOLSON PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:NICHOLSON PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARVICE
Authorized Official - Middle Name:GARRETT
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:205-377-6960
Mailing Address - Street 1:1912 MAYFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35226-3316
Mailing Address - Country:US
Mailing Address - Phone:205-377-6960
Mailing Address - Fax:205-449-2536
Practice Address - Street 1:216 LORNA SQ
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35216-5439
Practice Address - Country:US
Practice Address - Phone:205-377-6960
Practice Address - Fax:205-449-2536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH363261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1275651572OtherBLUE CROSS BLUE SHIELD