Healthcare Provider Details

I. General information

NPI: 1679756001
Provider Name (Legal Business Name): JORDAN NICHOLS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2007
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 N NORTHWEST HWY
PARK RIDGE IL
60068
US

IV. Provider business mailing address

135 N NORTHWEST HWY
PARK RIDGE IL
60068
US

V. Phone/Fax

Practice location:
  • Phone: 847-823-5077
  • Fax: 847-823-0371
Mailing address:
  • Phone: 847-823-5077
  • Fax: 847-823-0371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: JORDAN NICHOLS
Title or Position: OWNER
Credential: DPM
Phone: 847-823-5077