Healthcare Provider Details

I. General information

NPI: 1346617628
Provider Name (Legal Business Name): NICHOLAS INTERIAL PT,DPT,ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2015
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 VALLEY VIEW DR
MOLINE IL
61265-6133
US

IV. Provider business mailing address

5250 COMPETITION DR STE 100
BETTENDORF IA
52722-8837
US

V. Phone/Fax

Practice location:
  • Phone: 309-797-0866
  • Fax: 309-278-8831
Mailing address:
  • Phone: 563-449-7000
  • Fax: 563-449-7099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.021600
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: