Provider Demographics
NPI:1780280412
Name:NICHOLS, CHASE
Entity type:Individual
Prefix:
First Name:CHASE
Middle Name:
Last Name:NICHOLS
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 1262
Mailing Address - Street 2:
Mailing Address - City:CRESTONE
Mailing Address - State:CO
Mailing Address - Zip Code:81131-1302
Mailing Address - Country:US
Mailing Address - Phone:303-489-2316
Mailing Address - Fax:
Practice Address - Street 1:1502 E MIAMI ST.
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401
Practice Address - Country:US
Practice Address - Phone:303-489-2316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0009989225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist