Healthcare Provider Details

I. General information

NPI: 1992115992
Provider Name (Legal Business Name): NICHOLAS GELLER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: NICHOLAS HOULNE-GELLER ATC

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 FARMERS ROW
GROTON MA
01450-1848
US

IV. Provider business mailing address

1 DAYBROOK DR APT 314
AYER MA
01432-1730
US

V. Phone/Fax

Practice location:
  • Phone: 978-448-7532
  • Fax:
Mailing address:
  • Phone: 802-299-7257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2291
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: