Healthcare Provider Details

I. General information

NPI: 1902441298
Provider Name (Legal Business Name): CHRISTOPHER MICHAEL NICKLO HAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2019
Last Update Date: 11/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 SUTTER ST RM 1400
SAN FRANCISCO CA
94108-4003
US

IV. Provider business mailing address

5915 TAFT AVE
OAKLAND CA
94618-1740
US

V. Phone/Fax

Practice location:
  • Phone: 415-362-2901
  • Fax:
Mailing address:
  • Phone: 510-654-7548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number8558
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: