Provider Demographics
NPI:1780839852
Name:GLADFELTER, NICO (LAC)
Entity Type:Individual
Prefix:
First Name:NICO
Middle Name:
Last Name:GLADFELTER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:NICOLAUS
Other - Middle Name:
Other - Last Name:GLADFELTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:31 WHITE SWAN WAY
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-6285
Mailing Address - Country:US
Mailing Address - Phone:732-965-2016
Mailing Address - Fax:
Practice Address - Street 1:31 WHITE SWAN WAY
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-6285
Practice Address - Country:US
Practice Address - Phone:760-846-2873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-17
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12575171100000X
NJ25MZ00074100171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist