Provider Demographics
NPI:1013526128
Name:BROLIN, NICK
Entity Type:Individual
Prefix:
First Name:NICK
Middle Name:
Last Name:BROLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 519
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:WV
Mailing Address - Zip Code:25813-0519
Mailing Address - Country:US
Mailing Address - Phone:304-252-3394
Mailing Address - Fax:
Practice Address - Street 1:200 VINE ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-4844
Practice Address - Country:US
Practice Address - Phone:304-694-0942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator