Provider Demographics
NPI:1760532246
Name:NICHOLS, GERALD A (DC)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:A
Last Name:NICHOLS
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 1:140 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:EVART
Mailing Address - State:MI
Mailing Address - Zip Code:49631-5120
Mailing Address - Country:US
Mailing Address - Phone:231-734-5684
Mailing Address - Fax:231-734-5684
Practice Address - Street 1:140 N PINE ST
Practice Address - Street 2:
Practice Address - City:EVART
Practice Address - State:MI
Practice Address - Zip Code:49631-5120
Practice Address - Country:US
Practice Address - Phone:231-734-5684
Practice Address - Fax:231-734-5684
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004457111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI350011700OtherRR MEDICARE
MI950F750000OtherBCBS
MI950F750000OtherBCBS
MI350011700OtherRR MEDICARE