Healthcare Provider Details

I. General information

NPI: 1154394856
Provider Name (Legal Business Name): NICHOLAS DEWIT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 45TH AVE
MUNSTER IN
46321-3962
US

IV. Provider business mailing address

2045 PORTE DE LEAU CT #207
HIGHLAND IN
46322-2390
US

V. Phone/Fax

Practice location:
  • Phone: 219-922-8188
  • Fax:
Mailing address:
  • Phone: 219-781-3531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36001173A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: