Provider Demographics
NPI:1669418711
Name:NICHOLLS CLINIC
Entity type:Organization
Organization Name:NICHOLLS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSO
Authorized Official - Prefix:
Authorized Official - First Name:STARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-338-5263
Mailing Address - Street 1:806 N LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:NICHOLLS
Mailing Address - State:GA
Mailing Address - Zip Code:31554-4006
Mailing Address - Country:US
Mailing Address - Phone:912-345-0059
Mailing Address - Fax:912-345-0062
Practice Address - Street 1:806 N LIBERTY ST
Practice Address - Street 2:
Practice Address - City:NICHOLLS
Practice Address - State:GA
Practice Address - Zip Code:31554-4006
Practice Address - Country:US
Practice Address - Phone:912-345-0059
Practice Address - Fax:912-345-0062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAFLU127Medicare ID - Type UnspecifiedCOUNTY FLU BILLING #
GAGRP3496Medicare ID - Type UnspecifiedCOUNTY MDCR BILLING #