Healthcare Provider Details

I. General information

NPI: 1679562284
Provider Name (Legal Business Name): GARY LOYD NICKS P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC118 BOX 606
APO AE
09137
DE

IV. Provider business mailing address

PSC118 BOX 606
APO AE
09137
DE

V. Phone/Fax

Practice location:
  • Phone: 4-965-6169
  • Fax: 3183
Mailing address:
  • Phone: 4-965-6169
  • Fax: 3183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2000157969
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: