MEDICARE: DEANDRE NICHOLS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225400000X	Rehabilitation Practitioner		NV

General Provider Information

NPI Number	:	1013372663
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEANDRE NICHOLS

Provider Business Mailing Address
First Line	:	4325 W ROME BLVD
Second Line	:	APT #2014
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89084-5497
Country	:	US
Telephone Number	:	323-649-7196
Fax Number	:

Provider Business Practice Location Address
First Line	:	3755 W LAKE MEAD BLVD
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-4897
Country	:	US
Telephone Number	:	702-487-5665
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2015
Last Update Date	:	12/28/2015

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Directions to “ DEANDRE NICHOLS ” Practice Location

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