MEDICARE: NICHOLS THERAPY GROUP PC

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	225100000X	Physical Therapist	RPT1371	ID
2	225100000X	Physical Therapist	RPT1136	ID
3	225100000X	Physical Therapist	1136	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043380769
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NICHOLS THERAPY GROUP PC

Provider Business Mailing Address
First Line	:	9652 W STATE STREET
Second Line	:
City	:	STAR
State	:	ID
Zip	:	83669-5858
Country	:	US
Telephone Number	:	208-286-0766
Fax Number	:	208-286-0768

Provider Business Practice Location Address
First Line	:	9652 W STATE STREET
Second Line	:
City	:	STAR
State	:	ID
Zip	:	83669-5858
Country	:	US
Telephone Number	:	208-286-0766
Fax Number	:	208-286-0768

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. BRIAN DAVID NICHOLS
Credential	:	MPT
Telephone Number	:	208-286-0766

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	06/29/2012

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