Healthcare Provider Details

I. General information

NPI: 1780034272
Provider Name (Legal Business Name): MR. NICHOLAS GRAHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 W SELTICE WAY
COEUR D ALENE ID
83814-8921
US

IV. Provider business mailing address

PO BOX 1387
HAYDEN ID
83835-1387
US

V. Phone/Fax

Practice location:
  • Phone: 208-620-5255
  • Fax:
Mailing address:
  • Phone: 208-415-0299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number8921626
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: