Healthcare Provider Details

I. General information

NPI: 1962336081
Provider Name (Legal Business Name): NICHOLOS P BOLLIN MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3684 N CITRUS AVE
CRYSTAL RIVER FL
34428-6033
US

IV. Provider business mailing address

3684 N CITRUS AVE
CRYSTAL RIVER FL
34428-6033
US

V. Phone/Fax

Practice location:
  • Phone: 352-795-4114
  • Fax: 352-563-2438
Mailing address:
  • Phone: 352-795-4114
  • Fax: 352-563-2438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT22980
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: