MEDICARE: MR. DANDY NICHOLS NMT, LMT

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	172M00000X	Mechanotherapist	MT009639	GA
2	225700000X	Massage Therapist	MT009639	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MT009639	OTHER	GA	MASSAGE LICENSE

General Provider Information

NPI Number	:	1013469915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DANDY NICHOLS NMT, LMT

Provider Business Mailing Address
First Line	:	5966 HERITAGE LN
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30087-1858
Country	:	US
Telephone Number	:	512-589-7274
Fax Number	:

Provider Business Practice Location Address
First Line	:	6065 ROSWELL RD STE 170
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30328-4034
Country	:	US
Telephone Number	:	512-589-7274
Fax Number	:

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

Provider Enumeration Date	:	10/26/2016
Last Update Date	:	05/06/2024

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