Provider Demographics
NPI:1710589676
Name:KREZEK, NICHOLAS JOHNATHAN (NMT, MT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOHNATHAN
Last Name:KREZEK
Suffix:
Gender:M
Credentials:NMT, MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3126 62ND ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95820-1911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2390 E BIDWELL ST
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3872
Practice Address - Country:US
Practice Address - Phone:916-260-5843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-14
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83234225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist