Provider Demographics
NPI:1699859900
Name:NICOLAIDES, HENRY DELANO (DC)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:DELANO
Last Name:NICOLAIDES
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 1:601 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-2603
Mailing Address - Country:US
Mailing Address - Phone:618-529-5450
Mailing Address - Fax:618-549-4354
Practice Address - Street 1:601 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2603
Practice Address - Country:US
Practice Address - Phone:618-529-5450
Practice Address - Fax:618-549-4354
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT15043Medicare UPIN