Healthcare Provider Details

I. General information

NPI: 1982110706
Provider Name (Legal Business Name): SCOTT NICHOLS DPT, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 SIKES AVE
SIKESTON MO
63801-5021
US

IV. Provider business mailing address

1102 SIKES AVE
SIKESTON MO
63801-5021
US

V. Phone/Fax

Practice location:
  • Phone: 573-471-5755
  • Fax: 573-471-5884
Mailing address:
  • Phone: 573-471-5755
  • Fax: 573-471-5884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number118415
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number118530
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: