Healthcare Provider Details

I. General information

NPI: 1760449417
Provider Name (Legal Business Name): MICHAEL KENNETH NICOLAI DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 1ST AVE S
NEW ROCKFORD ND
58356-1807
US

IV. Provider business mailing address

207 1ST AVE S STE A
NEW ROCKFORD ND
58356-1800
US

V. Phone/Fax

Practice location:
  • Phone: 701-947-2121
  • Fax: 701-947-2012
Mailing address:
  • Phone: 701-947-2121
  • Fax: 701-947-2012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number573
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: