Healthcare Provider Details

I. General information

NPI: 1043207541
Provider Name (Legal Business Name): NICHOLAS JOHN ATHENS DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 08/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 INDUSTRIAL RD SUITE B
SAN CARLOS CA
94070-4153
US

IV. Provider business mailing address

951 INDUSTRIAL RD SUITE B
SAN CARLOS CA
94070-4153
US

V. Phone/Fax

Practice location:
  • Phone: 650-593-4447
  • Fax: 650-593-5071
Mailing address:
  • Phone: 650-593-4447
  • Fax: 650-593-5071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number15820
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: