Provider Demographics
NPI:1801393004
Name:OPENGO, NICHOLAS (LMT)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:OPENGO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6927 REX CT
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61102-1149
Mailing Address - Country:US
Mailing Address - Phone:779-423-5368
Mailing Address - Fax:
Practice Address - Street 1:1752 WINDSOR RD STE 202
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4276
Practice Address - Country:US
Practice Address - Phone:815-977-3747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist