Healthcare Provider Details

I. General information

NPI: 1821537390
Provider Name (Legal Business Name): SCOTT CRANDALL NICHOLSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2017
Last Update Date: 02/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 S MILTON RD #206
FLAGSTAFF AZ
86001-7302
US

IV. Provider business mailing address

901 E CRESTVIEW AVE
FLAGSTAFF AZ
86001-4759
US

V. Phone/Fax

Practice location:
  • Phone: 928-774-8407
  • Fax:
Mailing address:
  • Phone: 928-853-0937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-030789
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: