Healthcare Provider Details

I. General information

NPI: 1568818458
Provider Name (Legal Business Name): MICHAEL NICHOLS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2016
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 W CHERYL ST
OSCEOLA AR
72370-2837
US

IV. Provider business mailing address

114 W CHERYL ST
OSCEOLA AR
72370-2837
US

V. Phone/Fax

Practice location:
  • Phone: 870-622-0073
  • Fax: 870-622-0071
Mailing address:
  • Phone: 870-622-0073
  • Fax: 870-622-0071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: