Provider Demographics
NPI:1881874626
Name:BUSH, NICHOLAS C JR (BA)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:C
Last Name:BUSH
Suffix:JR
Gender:M
Credentials:BA
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 9054
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-9054
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:318 DONNELLY ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN CITY
Practice Address - State:TN
Practice Address - Zip Code:37683-1510
Practice Address - Country:US
Practice Address - Phone:423-727-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator