Healthcare Provider Details

I. General information

NPI: 1922424373
Provider Name (Legal Business Name): NICHOLAS PERRY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2014
Last Update Date: 03/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 COMER AVE
COLUMBUS GA
31904-8725
US

IV. Provider business mailing address

28B CROSSWINDS RD
PHENIX CITY AL
36869-7416
US

V. Phone/Fax

Practice location:
  • Phone: 706-321-9606
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: