MEDICARE: MR. RICHARD JESSE NICHOLSON

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1578740247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICHARD JESSE NICHOLSON

Provider Business Mailing Address
First Line	:	1041 E RIVER DR
Second Line	:
City	:	LAKE LUZERNE
State	:	NY
Zip	:	12846-2305
Country	:	US
Telephone Number	:	518-964-6773
Fax Number	:	518-964-6735

Provider Business Practice Location Address
First Line	:	1041 E RIVER DR
Second Line	:
City	:	LAKE LUZERNE
State	:	NY
Zip	:	12846-2305
Country	:	US
Telephone Number	:	518-964-6773
Fax Number	:	518-964-6735

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

Provider Enumeration Date	:	01/24/2008
Last Update Date	:	01/24/2008

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