Healthcare Provider Details

I. General information

NPI: 1104738426
Provider Name (Legal Business Name): MR. NICHOLAS EUGENE FAULKNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 RICHARDSON CORNER RD
CHARLTON MA
01507-1431
US

IV. Provider business mailing address

PO BOX 90
CHARLTON MA
01507-0090
US

V. Phone/Fax

Practice location:
  • Phone: 774-230-5173
  • Fax: 774-230-5173
Mailing address:
  • Phone: 774-230-5173
  • Fax: 774-230-5173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number24011228-MT-MT
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: