Healthcare Provider Details

I. General information

NPI: 1255616967
Provider Name (Legal Business Name): NICHOLAS RICH KOREERAT DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2011
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 ROCKVILLE PIKE
BETHESDA MD
20889-5674
US

IV. Provider business mailing address

1061 HARMON AVE
FORT STEWART GA
31314-5674
US

V. Phone/Fax

Practice location:
  • Phone: 301-400-2555
  • Fax:
Mailing address:
  • Phone: 912-435-6780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL.0011450
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL-11450
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: