Healthcare Provider Details

I. General information

NPI: 1669424784
Provider Name (Legal Business Name): CAYLOR NICKEL CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 10/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CAYLOR NICKEL SQ
BLUFFTON IN
46714-2529
US

IV. Provider business mailing address

1 CAYLOR NICKEL SQ
BLUFFTON IN
46714-2529
US

V. Phone/Fax

Practice location:
  • Phone: 260-919-3302
  • Fax: 260-919-3551
Mailing address:
  • Phone: 260-919-3302
  • Fax: 260-919-3551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIMBERLY S BUMGARNER
Title or Position: DIRECTOR HUMAN RESOURCES
Credential:
Phone: 260-919-3302