Healthcare Provider Details

I. General information

NPI: 1699690396
Provider Name (Legal Business Name): MR. NICHOLAS CHAMPE TYNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 H ST
EUREKA CA
95501-1026
US

IV. Provider business mailing address

622 H ST
EUREKA CA
95501-1026
US

V. Phone/Fax

Practice location:
  • Phone: 707-582-3246
  • Fax: 707-445-7143
Mailing address:
  • Phone: 707-582-3246
  • Fax: 707-445-7143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number1A46CB1411
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: