Healthcare Provider Details

I. General information

NPI: 1639430564
Provider Name (Legal Business Name): NICOLE B SCALES O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MARCELL DR NE STE A
ROCKFORD MI
49341-1362
US

IV. Provider business mailing address

120 MARCELL DR NE STE A
ROCKFORD MI
49341-1362
US

V. Phone/Fax

Practice location:
  • Phone: 616-866-0140
  • Fax: 616-866-8694
Mailing address:
  • Phone: 616-866-0140
  • Fax: 616-866-8694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004697
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: