Provider Demographics
NPI:1912412636
Name:MCNICHOLAS, MATTHEW JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JAMES
Last Name:MCNICHOLAS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 LONG HILL RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-4166
Mailing Address - Country:US
Mailing Address - Phone:860-448-2225
Mailing Address - Fax:860-446-0784
Practice Address - Street 1:565 LONG HILL RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4166
Practice Address - Country:US
Practice Address - Phone:860-448-2225
Practice Address - Fax:860-446-0784
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2043111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor