Healthcare Provider Details

I. General information

NPI: 1003495052
Provider Name (Legal Business Name): NICHOLAS JOHN BELLACICCO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 06/29/2025
Certification Date: 06/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 MEMORIAL RD STE 508
WEST HARTFORD CT
06107-4233
US

IV. Provider business mailing address

65 MEMORIAL RD STE 508
WEST HARTFORD CT
06107-4233
US

V. Phone/Fax

Practice location:
  • Phone: 860-696-2925
  • Fax:
Mailing address:
  • Phone: 860-696-2925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number81124
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: