Provider Demographics
NPI:1811987696
Name:NICHOLS CLINIC LLC
Entity type:Organization
Organization Name:NICHOLS CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:SAAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-259-7334
Mailing Address - Street 1:1002 S BROADWAY ST STE 7
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-1463
Mailing Address - Country:US
Mailing Address - Phone:606-754-5076
Mailing Address - Fax:606-754-5557
Practice Address - Street 1:220 ELKHORN ST
Practice Address - Street 2:
Practice Address - City:ELKHORN CITY
Practice Address - State:KY
Practice Address - Zip Code:41522
Practice Address - Country:US
Practice Address - Phone:606-754-5076
Practice Address - Fax:606-754-5557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336C0003X
KY1321332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1812824OtherNABP
KY54016340Medicaid
KY90120981OtherDME MEDICAID
KY54016340Medicaid