Healthcare Provider Details

I. General information

NPI: 1164819470
Provider Name (Legal Business Name): NICHOLAS SPANGLER DAT LAT ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9042 COLUMBIA AVE
MUNSTER IN
46321-2927
US

IV. Provider business mailing address

10163 OLCOTT AVE
SAINT JOHN IN
46373-9539
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-4461
  • Fax:
Mailing address:
  • Phone: 219-798-6850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36002615A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: