Healthcare Provider Details

I. General information

NPI: 1194984443
Provider Name (Legal Business Name): PHIL JAMES NYDEREK SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 ASHMOORE DRIVE
GREENUP KY
41144
US

IV. Provider business mailing address

103 ASHMOORE DRIVE
GREENUP KY
41144
US

V. Phone/Fax

Practice location:
  • Phone: 740-821-6973
  • Fax: 606-473-1389
Mailing address:
  • Phone: 740-821-6973
  • Fax: 606-473-1389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: