Healthcare Provider Details

I. General information

NPI: 1164734893
Provider Name (Legal Business Name): NICHOLAS JAMES FLYNN A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2010
Last Update Date: 11/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 EL JOBEAN RD
PORT CHARLOTTE FL
33948-1120
US

IV. Provider business mailing address

2300 EL JOBEAN RD
PORT CHARLOTTE FL
33948-1120
US

V. Phone/Fax

Practice location:
  • Phone: 727-808-3814
  • Fax:
Mailing address:
  • Phone: 727-808-3814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: