Provider Demographics
NPI:1619485455
Name:DENIS, NICOLAS JR
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:DENIS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3630 NANTUCKET ISLAND DR APT 204
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-5341
Mailing Address - Country:US
Mailing Address - Phone:386-931-4272
Mailing Address - Fax:
Practice Address - Street 1:565 MEMORIAL CIR
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5001
Practice Address - Country:US
Practice Address - Phone:386-310-8766
Practice Address - Fax:386-310-8770
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-15
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA68079225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist