Healthcare Provider Details

I. General information

NPI: 1942534441
Provider Name (Legal Business Name): NICHOLAS CICERO IV DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59295 RIVER WEST DRIVE
PLAQUEMINE LA
70764
US

IV. Provider business mailing address

3797 BIGMAN LANE
TORBERT LA
70762
US

V. Phone/Fax

Practice location:
  • Phone: 225-687-2066
  • Fax: 225-687-2067
Mailing address:
  • Phone: 225-939-3923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number07694
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: