Provider Demographics
NPI:1912577396
Name:NICHOLS, RYAN (DC)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:NICHOLS
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 1:5561 DANIEL DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BELOIT
Mailing Address - State:IL
Mailing Address - Zip Code:61080-2370
Mailing Address - Country:US
Mailing Address - Phone:815-494-9980
Mailing Address - Fax:
Practice Address - Street 1:111 N MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-3072
Practice Address - Country:US
Practice Address - Phone:608-754-8977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5666-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor